North Dakota Public Employees Retirement System

Forms

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Agreement/Waiver of Participation for Optional Defined Contribution Plan (SFN 54366)
Agreement/Waiver of Participation for Optional Retirement (SFN 17627)
Application for Conversion of Group Life Insurance
Application for Job Service Retirement Benefits (SFN 53837)
Authorization for Automatic Premium Deduction (SFN 50134)
Authorization for Direct Deposit for Annuity Payment (SFN 18379)
Authorization for Direct Deposit of FlexComp Reimbursements (SFN 53852)
Authorization for Withholding Federal Income Tax (SFN 17628)
Authorization for Withholding ND State Income Tax (SFN 17629)
CatchUp Worksheet for the Deferred Compensation Plan (SFN 51501)
Continuation of Group Dental Insurance Coverage (COBRA) (SFN 53535)
Continuation of Group Health Coverage (COBRA) (SFN 14120)
Continuation of Group Vision Insurance Coverage (COBRA) (SFN 53536)
Deferred Compensation Plan Catch-Up Worksheet (SFN 51501)
Deferred Compensation Plan Participant Agreement (SFN 3803)
Deferred Compensation Plan Request for Transfer (SFN 50177)
Defined Contribution Plan Election Form (SFN 52170)
Dental Insurance Enrollment/Change Form (active members)
Designation of Beneficiary for the Group Retirement Plan (SFN 2560)
Employee Selection Form for the Exclusive Provider Organization (EPO)
Employee's Membership Application for the Defined Benefit Plan (SFN 2561)
Employee's Membership Application North Dakota Highway Patrol Retirement (SFN 16914)
Employer Payment Plan (SFN 52799)
Expedited Deferred Comp Plan & PEP Enrollment (SFN 54362)
Form W4-P (Substitute) Tax Withholding Certificate (SFN 51506)
Group Life Insurance Disability Benefit Attending Physician Statement
Group Life Insurance Evidence of Insurability
Group Vision Insurance Claim Form
Health Benefit Plan Affiliation & Out-of-Area Waiver Form
Living Benefit Option Claim Form
Meeting Request & Registration Form (SFN 53176)
Mutual Fund Window Election (SFN 53082)
NDPERS Group Health Application
National Guard/Law Enforcement Retirement Plan Enrollment Form (SFN 17874)
NDPERS Group Life Insurance Designation of Beneficiary/Change Form (SFN 53855)
NDPERS Group Life Insurance Enrollment/Change Form(SFN 53803)
NDPERS Request for Benefit Information (SFN 53603)
NDPERS Request for Conversion Information (Life Insurance)
Notice of Appointment of Authorized Agent (SFN 17029)
Notice of Change (for name and/or address change) (SFN 10766)
Notice of Death/Application for Surviving Spouse Benefits (SFN 14137)
Notice of Death/Application for Surviving Spouse Benefits - Alternate Retirement Systems (SFN 52254)
Notice of Irregular Salary or No Deposit (SFN 53707)
Notice of Membership Transfer to TIAA-CREF (SFN 50084)
Notice of Status or Employment Change (SFN 53611)
Notice of Transfer (SFN 53706)
Participant Agreement for the Deferred Compensation Plan (SFN 3803)
Purchase Agreement for USERRA Covered Military Active Duty (SFN 17758)
Record of Previous Public Employment (SFN 17028)
Re-employment of a Defined Contribution Plan Member (SFN 53286)
Request for Deminimus Distribution (SFN 52051)
Request for Purchase Information (SFN 53718)
TFFR Payroll Deduction Authorization (SFN 19182)
Transfer of Unused Sick Leave Verification (SFN 53404)
Verification of Out-of-State or Federal Retirement Credit (SFN 19397)
Vision Insurance Enrollment/Change Form (active members)
Waiver of Health Coverage
Waiver of Membership for Elected Officials (SFN 53405)

Employees of the University System and Political Subdivisions SHOULD NOT USE THE FOLLOWING FLEXCOMP FORMS. Please contact your payroll/human resource office for the proper forms.

Annual FlexComp Enrollment 2004 Plan Year (SFN 53851)
Authorization for Direct Deposit of FlexComp Reimbursements (SFN 53852)
Change in Status (SFN 53511)
Continuation of Coverage in a Medical Spending Account (SFN 53512)
FlexComp Reimbursement Voucher (print version) (fillable version) (SFN 16868)

Kits

Deferred Retirement Kit (SFN 53724)
Notice of Transfer Kit (SFN 53728)
Refund/Rollover Kit (SFN 53725)
Retirement Kit (SFN 53723)