Form NAVMC 12000/499 NAVMC 12000/499 Marine Corps NAF Group Insurance and Retirement Agreemen

MCO P12000.11A

CUI (when filled in)

OMB No. 0703 - 0071

MARINE CORPS NAF GROUP INSURANCE AND RETIREMENT AGREEMENT

OMB approval expires: Pending

Important: Please read the Privacy Act Statement and instructions before filling in this form.
1. Employee / Retiree Information
The Employee is: (place an "X" in the appropriate box)

an active employee

1a. Name (Last,
First, Middle Initial)

a retiree

1b. ID Number

1d. Current Employer
(Full name of Command)

1c. Current Employment Date

1e. Previously insured
under this plan by:

2. Medical Plan Options
Aetna Choice Point-of-Service II (Aetna CP II)
Kaiser California (KAICA)

Aetna Traditional Choice (Aetna TC)

Kaiser Mid Atlantic (KAIMA)

Aetna High Deductible Health Plan (HDHP)

Kaiser Hawaii* (KAIHI)

HMSA*

3. Dental Plan Options
Aetna Dental**

Kaiser Hawaii Dental* (KAISHI)

HMSA HMO Dental* (HMSAD)

HMSA PPO Dental* (HMSAPPO)

Stand Alone Dental*** (SAD)

4. Elected Insurance Coverage
4a. Name (Last, First, Middle Initial)

4b. Date of
Birth

4c.
4d. Social
4e.
4f.
4g.
4h.
4i.
4j.
4k.
4l.
4m. 4n.
4o.
4p.
4q.
4r.
Relationship Security Number STD OPT OPT DEP DEP. DEP DEP Aetna Aetna Aetna HMO Aetna HMO SAD
****
Life Life 1 Life 2 Life 1 Life 2 Life 3 Life 4 CP II TC HDHP Med Dent Dent

DRAFT
4s. Check if additional beneficiary(ies) are included on continuation page NAVMC 12000/499C.
AD&D is available to Active Employees only. Standard Life Insurance is required for any Optional Life coverage and Dependent Life coverage.
*Coverage is mandated by geographic location.
**Medical enrollment is required for dental enrollment with Aetna Dental.
***Retirees are not eligible for SAD coverage.
****Documentation required.

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NAVMC 12000/499 (XX-22)
Previous editions are obsolete

Print Form

Controlled by: USMC
Controlled by: HQMC M&RA MR, MRG
CUI Category: PRVCY
Distribution/Dissemination: FEDCON
POC: [email protected]

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MCO P12000.11A

CUI (when filled in)

MARINE CORPS NAF GROUP INSURANCE AND RETIREMENT AGREEMENT (CONTINUED)
5. Election / Change
5a. I Elect to:
Waive all coverage

Cancel all coverage

Waive enrollment in the Retirement Plan

Opt out of the Premium Conversion Plan (Section 125)

Change coverage (explain in 5b below)

Update Beneficiary Information

Cancel participation in the Retirement Plan

5b. Explanation
of Change

Marine Corps NAFI Designation of Beneficiary(ies)
6. Information About Each Beneficiary for NAF Group Life Insurance
6a.

6b.
First Name, Middle Initial,
and Last Name

6c.
Social Security
Number

Address (including ZIP code)

DRAFT

6g. Check if additional beneficiary(ies) are included on continuation page NAVMC 12000/499C.

6d.
Date of Birth

6e.

6f.
Relationship
to You

Percentage
for Each Beneficiary

6h. Percentage Total

7. Information About Each Beneficiary for NAF Group Retirement Plan

If married, the spouse must be the beneficiary or if designating someone other than the spouse, spousal signature waiving beneficiary designation is required.
7a.
7b.
7c.
7d.
7e.
First Name, Middle Initial,
Address (including ZIP code)
Social
Date of
Relationship
and Last Name
Security Number
Birth
to You

7g. Check if additional beneficiary(ies) are included on continuation page NAVMC 12000/499C.
Skip to section 9 if
the spouse is not currently waiving
beneficiary designation.

7i. Printed Name
of Spouse

7f.
Percentage
for Each Beneficiary

7h. Percentage Total
7k. Date Signed

7j. Spouse
Signature
CUI (when filled in)

NAVMC 12000/499 (XX-22)
Previous editions are obsolete

Print Form

Controlled by: USMC
Controlled by: HQMC M&RA MR, MRG
CUI Category: PRVCY
Distribution/Dissemination: FEDCON
POC: [email protected]

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AEM Form Designer 6.5

MCO P12000.11A

CUI (when filled in)

MARINE CORPS NAF GROUP INSURANCE AND RETIREMENT AGREEMENT (CONTINUED)
8. Spouse Signature Waiving Survivor Annuity (Section 8 is completed at time of retirement only, and once completed, the designation is irrevocable.)
Skip section 8 if not married or married and not naming someone other than your spouse as the retirement plan beneficiary.
By signing below, I freely consent to waive the survivor spouse annuity benefit under the Marine Corps NAF Group Retirement Plan.
I understand that by signing below that I will not be the designated beneficiary for my spouse's Group Retirement Plan and will not be entitled to any benefit
(lifetime periodic payment or lump sum payment) under the Group Retirement Plan.
8a. Printed Name
of Spouse

8c. Date Signed

8b. Spouse
Signature

Note: Items 8d-8h are completed by an impartial witnessing authority (either a Notary Public or an Authorized NAF Group Retirement Plan Representative).
I certify that the person named in Item 8a presented identification (or was known) to me, gave consent, signed or marked this form, and
acknowledged that the consent was freely given in my presence.
8h. Notary Stamp or Seal
8d. Printed Name
8f. Date
8e. Signature of
and Title of
Witnessed
Witnessing
Witnessing
Representative or
Authority
Notary Public.
Note: if Notary Public,
place notary stamp or
seal in the space to
the right (item 8h).
9. Requesting Employee / Retiree Signature
9a. Requesting Employee / Retiree Signature
Complete Section 10 for Active Employees Only

8g. Expiration date
of commission,
if Notary Public

DRAFT

9b. Date Signed

10. Authorized NAF Employer HR Representative Signature (not eligible to receive payment as a beneficiary)
10a.
Printed Name and
Title of HR
Representative

10b.
Date Signed

10c.
HR Representative's
Signature

CUI (when filled in)

NAVMC 12000/499 (XX-22)
Previous editions are obsolete

Print Form

Controlled by: USMC
Controlled by: HQMC M&RA MR, MRG
CUI Category: PRVCY
Distribution/Dissemination: FEDCON
POC: [email protected]

Page of

Reset Form

AEM Form Designer 6.5

MCO P12000.11A

CUI (when filled in)

INSTRUCTIONS FOR COMPLETING NAVMC 12000/499
MARINE CORPS NAF GROUP INSURANCE AND RETIREMENT AGREEMENT
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, [OMB Control Number 0703-0071] is estimated to average [15 minutes] as appropriate per response, including the time for
reviewing instruction, searching data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid
OMB control number.
RECORDS MANAGEMENT
DON Records Schedule 12000-18 - Employee Management Administrative Records: "Temporary: Destroy when 3 years old, but longer retention is authorized if required for business use."
PRIVACY ACT STATEMENT
Authority: 10 U.S.C. 5013; 10 U.S.C. 5042; 10 U.S.C. 136; SECNAVINST 12250.6B; MCO P12000.11A, as amended; and SORNs A0215-1a FMWRC DoD and N12293-1.
Purpose: Information provided will be used for data management and administration of benefits and retirement plans for Marine Corps NAF personnel and retirees, and for reporting and
documentation required in connection with these actions.
Routine Uses: While the information requested on this form is intended to be primarily for internal purposes, in certain circumstances it may be necessary to disclose this information externally.
For example, information may be disclosed to authorized benefits providers, to banking institutions for payroll processing, and to taxing authorities to meet reporting requirements. Complete lists
and explanations of applicable routine uses are available in the authorizing SORNs accessible at https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-Component-Notices/.
Disclosure: Voluntary; however, failure to provide the requested information may result in the personnel's / retiree's coverage being delayed, denied, or continued in error.
General Information
REQUEST FOR ENROLLMENT/WAIVER/CHANGE IN GROUP INSURANCE (STANDARD PLAN OR HEALTH MAINTENANCE ORGANIZATION) AND RETIREMENT PLAN, AS APPLICABLE.
I hereby request my employer to arrange for Insurance coverage indicated to which I am entitled, or to which I may become entitled under the terms of the group policies, Health Maintenance
Organization contracts or self-insured contracts, issued to my employer by the Contractor, Insurance company or Health Maintenance Organization. I understand that if I have not indicated a
request for all the coverage to which I am entitled, that if I request it at a later date, I may be required to (1) furnish at my own expense, evidence of qualifying event, or (2) wait until such time as an
open enrollment may be held. I understand that all my coverage will automatically cease upon termination of employment or change in eligible employment category or failure to remit premiums as
required, except that if an insured's death should occur within 31 days thereafter, the life insurance death benefit will be payable.

DRAFT

Premium Conversion Plan (Section 125 IRS code) - provisions of the IRS code section 125 allow medical and dental premiums to be deducted pre-tax, thus reducing an employee’s taxable gross
earnings. By participating in the section 125 tax deferral plan, participants are mandated to comply with IRS coverage regulations. Participation in the premium conversion plan is automatic. If you
do not want to participate you must opt out annually. Refer to your Employee Benefits Handbook or contact your local personnel office, for additional information.
Your election for participation or changes will not be valid without a signature where indicated (excludes any changes required by law, court order, or plan provisions).
Section 1. Employee Information
Item 1a.
Item 1b.
Item 1c.
Item 1d.
Item 1e.

Fill in Employee full name (last, first, and middle initial).
Fill in Employee employee ID number. If not known, leave blank.
Fill in date of hire at current employment location.
If an active employee, include your current employer's Command name. If retired, leave blank.
Fill in previous NAF employer. If no previous NAF employment, leave blank.

Sections 2 and 3. Medical and Dental Plan Options
Check the box(es) for option(s) elected.

CUI (when filled in)

NAVMC 12000/499 (XX-22)
Previous editions are obsolete

Print Form

Controlled by: USMC
Controlled by: HQMC M&RA MR, MRG
CUI Category: PRVCY
Distribution/Dissemination: FEDCON
POC: [email protected]

Page of

Reset Form

AEM Form Designer 6.5

MCO P12000.11A

CUI (when filled in)

INSTRUCTIONS FOR COMPLETING NAVMC 12000/499
MARINE CORPS NAF GROUP INSURANCE AND RETIREMENT AGREEMENT (CONTINUED)
Section 4. Insurance Options
Item 4a. Fill in the name of the insured individual..
Item 4b. Fill in the insured's date of birth.
Item 4c. Fill in the relationship of the insured individual to the employee (such as self, spouse, or child.).
Item 4d. Fill in the full Social Security Number (SSN) of the insured.
Items 4e-4r. Check the box(es) for option(s) elected.
Item 4s. Check if additional beneficiary(ies) are included on continuation page NAVMC 12000/499C.
Section 5. Election / Change
Item 5a. Check the applicable box(es).
Item 5b. Fill in an explanation of the changes you are requesting.
Section 6. Information About Each Beneficiary for NAF Group Life Insurance
Item 6a. Fill in the full name of the NAF Group Life Insurance beneficiary (first name, middle initial, last name).
Item 6b. Fill in the NAF Group Life Insurance beneficiary mailing address (to include ZIP code).
Item 6c. Fill in the SSN of the NAF Group Life Insurance beneficiary.
Item 6d. Fill in the date of birth of the NAF Group Life Insurance beneficiary.
Item 6e. Fill in the NAF Group Life Insurance beneficiary's relationship to you (such as spouse or child).
Item 6f. Fill in the percentage and insurance type for each NAF Group Life Insurance beneficiary.
Item 6g. Check if additional beneficiary(ies) are included on continuation page NAVMC 12000/499C.
Item 6h. Fill in the percentage total.
Section 7. Information about Each Beneficiary for NAF Group Retirement Plan
For section 7, if married, the spouse must be the designated beneficiary unless the spousal waiver is signed. The spousal waiver and/or beneficiary designation may be changed at any time.
Item 7a. Fill in the full name of the NAF Group Retirement Plan beneficiary (first name, middle initial, and last name).
Item 7b. Fill in the mailing address of the NAF Group Retirement Plan beneficiary (including ZIP Code).
Item 7c. Fill in the full SSN of the NAF Group Retirement Plan beneficiary.
Item 7d. Fill in the date of birth of the NAF Group Retirement Plan beneficiary.
Item 7e. Fill in the relationship (such as spouse or child) of the NAF Group Retirement Plan beneficiary.
Item 7f. Fill in the percentage for each beneficiary.
Item 7g. Check if additional beneficiary(ies) are included on continuation page NAVMC 12000/499C.
Item 7h. Fill in the percentage total.
Items 7i-7k are only completed if the spouse is currently waiving beneficiary designation.
Section 8. Spouse Signature Waiving Survivor Annuity (Section 8 is completed at time of retirement only, and once completed, the designation is irrevocable.)
Skip section 8 if not married or married and not naming someone other than your spouse as the retirement plan beneficiary.
Item 8a. Print the name of the spouse (first name, middle initial, and last name).
Item 8b. Spouse signature must be in the presence of either a Notary Public or Authorized NAF Group Retirement Plan Representative.
Item 8c. Fill in the date signed.
Items 8d-8h are completed by the witnessing authority (either a Notary Public or Authorized NAF Group Retirement Plan Representative).
Note: A witnessing authority is not eligible to receive payment as a beneficiary.
Section 9. Employee / Retiree Signature
Item 9a. Employee / Retiree signature.
Item 9b. Fill in the date signed.
Section 10. Authorized NAF Employer HR Representative Signature
An authorizing NAF Employer HR representative is not eligible to receive payment as a beneficiary.
10a. Print the name and title of the authorized NAF Employer HR Representative.
10b. Fill in the date signed.
10c. Authorized NAF Employer HR Representative signature.

DRAFT

CUI (when filled in)

NAVMC 12000/499 (XX-22)
Previous editions are obsolete

Print Form

Controlled by: USMC
Controlled by: HQMC M&RA MR, MRG
CUI Category: PRVCY
Distribution/Dissemination: FEDCON
POC: [email protected]

Page of

Reset Form

AEM Form Designer 6.5