Retiree Medical Benefits Payment

Please fill in the name of the Stetson University retiree and the name of the insured if different from the retiree (e.g., spouse of retiree).

Retiree Information

First Name

Middle Name

Last Name

Retiree's Street 1

Retiree's Street 2

Retiree's City

Retiree's State/Province

Retiree's ZIP/Postal Code

Retiree's Country

First Name

Middle Name

Last Name

Is the Insured's Address Different than Retiree?

Insured's Street 1

Insured's Street 2

Insured's City

Insured's State/Province

Insured's ZIP/Postal Code

Insured's Country

For assistance, contact Claudine Verdone at [email protected] or 386-822-7030.

Payment Type

Amount

$