Enter your information below.
If you have questions about what to enter in specific fields, hover on the for details.

Health Plan Information

Expected Health Insurance Coverage Level in Retirement:
Expected Health Insurance Carrier in Retirement:
Do you expect to enroll in Uniform Dental in retirement?
Do you expect to enroll in the High Deductible Health Plan (HDHP) in retirement?
Percentage you believe your health insurance premium will increase each year: %

Personal Information

Employee Name (optional):
Employee Birth Date:

Do you have a spouse?
Spouse Birth Date:
Expected Retirement Date:

Employment Information

Employment Category:
Appointment Status:
Appointment Percentage: %
Continuous Service Date:
Estimated Highest Wage at Retirement (Enter your expected highest wage rate or enter your current wage rate and predicted annual increase)
Estimated Annual Rate of Wage Increase Until Retirement: %
Current Sick Leave Balance: hours
Expected Annual Sick Leave Usage (Optional) hours