F00018 Retiree Medical Insurance Plan (RMIP): Non-U.S. National Health Plan (NHP) Transmittal Form


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This form filler tool is designed to assist you in electronically entering your data and printing a paper form with a unique barcode corresponding to your entered data. Once you've completed your answers and printed the form, you'll need to submit it either by email or in person, depending on the form type.  Please note that the data you enter is directly captured in the form's unique barcode, so it's important that you do not make any handwritten changes, corrections, or additions to the data or to the form after it has been printed. Doing so may result in data errors and processing delays.

In case you notice any errors after printing your form, or if you've left a field blank, we recommend starting over and completing a new form. It's also important to remember that your information is not saved by the form filler and can no longer be accessed after you print it. Therefore, please be extra careful in reviewing your answers, as it is impossible to make any corrections after the form is printed.

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Information on Completing the Form

This form should be used by a retiree MIP (RMIP) participant to transmit new or previously unrecorded Non-U.S. National Health Plan (NHP) enrollment information. Participation in the NHP of the country of pension address is mandatory for RMIP participants and their spouses/registered domestic partners, if the participant(s) are eligible on the same basis as nationals of the country of pension address record. 

Please return this signed form to HR Operations  (Select one transmittal format, and submit only once):

a.  E-mail at hroperations@worldbank.org         

b.  Mail to: HR Operations, World Bank MSN G2-202, P.O.Box:1420, Landover MD 20785, USA

c.  Fax +1 (202) 522-7026

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 25 Apr 2023

Retiree Information

Retiree UPI*

Retiree Name*


Select Members*

Eligible Member

For each retiree or spouse/domestic partner who has become eligible for a National Health Plan please provide the following information


Effective Date of Coverage*

Select one*


You must attach a copy of each individual's National Health Plan card to this application


Printed Name

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.