2026_Retiree_Benefits_MWAA | Page 14

PLEASE PRINT

1. SUBSCRIBER INFORMATION NAME( First, Last, MI) SOCIAL SECURITY NO.

HOME ADDRESS( Street, City, State, ZIP Code) HOME PHONE

STATUS � Retiree under age 65 � Retiree 65 and over � Survivor

2. MEDICAL PROVIDER / COVERAGE 3. DENTAL PROVIDER / COVERAGE 4. VISION PROVIDER / COVERAGE

� United Healthcare Choice

� United Healthcare Choice Plus

� United Healthcare Medicare Advantage

� Kaiser Permanente

� Kaiser Permanente Medicare Advantage

� Waive Coverage

Coverage Category

� Retiree Only

� Retiree + Child( ren)

� Retiree + Spouse

� Family

� Retiree + Domestic Partner

� Family + Domestic Partner

� United Concordia

� Waive Coverage

Coverage Category

� Retiree Only

� Retiree + Child( ren)

� Retiree + Spouse

� Family

� Retiree + Domestic Partner

� Family + Domestic Partner

� National Vision Administration

� Waive Coverage

Coverage Category

� Retiree Only

� Retiree + Child( ren)

� Retiree + Spouse

� Family

� Retiree + Domestic Partner

� Family + Domestic Partner

5. ENROLLMENT INFORMATION( If your dependent child is 26 years or older, you must submit proof of disability for coverage to continue.)

NAME( First, Last, MI) SOCIAL SECURITY NO. MEDICARE ID NO. DOB( MM / DD / YY)

I have read the information provided to me describing the Airports Authority Medical / Dental / Vision Insurance Program and make the elections shown on this form. I understand that I may change my elections by notifying the Benefits and Retirement Department.