How Do I Set Up Insurance Payee under HELPS? (cont.)

Filling Out the Form

• Complete the Retiree Information portion:
  • Your name
  • Social Security Number
  • Mailing address
  • Phone number
  • Last employing city
    
• Complete the Payment Information portion:
  • Who to pay
  • Account / policy number
  • Remittance address for payments
  • Phone number (insurance contact)
  • Monthly deduction amount
  • Effective date (NOTE: first deduction will occur the month after the month the form is received)
  • Name of company, if different from payee name
• Retiree Certification – your signature is required. Be sure to sign and date the form.
  
• The city must fill out the City Certification portion at the bottom of the form:
  • Indicate Public Safety Officer capacity