for Direct Deposit of Retiree Pension Benefits
of Beneficiary Form Adobe
Federal Tax Withholding Form W-4P Adobe
New Jersey Tax Withholding Form NJ W-4P Adobe
Duplicate Form 1099-R available on MBOS.
Registered MBOS Users: Log on here. New to MBOS: Register or learn more about MBOs here.
Retiree Change of Address — Change your address by phone — online using MBOS — or by mail
Waiver or Restoration of Pension Allowance Adobe
HEALTH BENEFITS FORMS
Retired Change of Status Application — PPO and HMO Plans Adobe PDF (39K) or High Deductible Health Plans Adobe PDF (36K)
Enrolled retirees who are changing plans or coverage levels.
Retired Coverage Enrollment Application — PPO and HMO Plans Adobe PDF (39K) or High Deductible Health Plans Adobe PDF (35K)
New enrollments ONLY.
NJ DIRECT Claim Form for Out-of-Network claims Adobe PDF (204K)
Aetna plan claims, contact Aetna directly
Retiree Dental Expense Plan (Aetna) Claim Form Adobe PDF (149K)
Express Scripts/Medco Mail-Order Form Adobe PDF (95K)
Express Scripts/Medco Prescription Drug Reimbursement Form Adobe PDF (112K)
Tax Certification - Domestic Partner Benefit Form Adobe
WELLNESS PLAN FORMS - State Retirees Only
For State retirees who attained 25 years of service after June 30, 2007 and before June 28, 2011.
Wellness Program Letter and Pledge Form Adobe PDF (54K)
NJ DIRECT Retiree Wellness Brochure Adobe PDF (505K)
NJ DIRECT Annual Wellness Certification Adobe PDF (96K)
For Aetna Wellness information and forms visit: aetnastatenj.com/wellness.php