F02368 Retiree Life Event & MBP Enrollment Request

Instructions:

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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.

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Information on Completing the Form 

  • This form must be completed electronically. 

  • Complete relevant sections: Reporting of life events must be made within 60 days from the life event date for other scenarios should be reported within 60 days from the end of active coverage date. 

  • If you do not request enrollment in the RMBP within 60 days from end of active coverage and then later request enrollment in the RMBP, you must provide evidence of coverage for three consecutive years, if applicable, by another medical insurance plan for the period immediately prior to requesting enrollment in RMBP. Proof of coverage must be produce from end of active coverage until the RMBP start date. 

  • Save form by clicking on “Save As PDF” on Completing the Form page. 

  • Supporting documentation that are not in English, a translation must be provided. 

  • Staff member signs, dates, and submits the form to HR Operations (please select one transmittal format, and submit only once): 
    Fax: +1-202-522-7026 or Email: hroperations@worldbank.org

Please Note: If you enroll in RMBP then request to end coverage for yourself or an enrolled dependent, you cannot request enrollment at a future date. Enrollment is a one-time opportunity. Use this form to report retiree life events or for retiree/surviving spouse/dependent to request enrollment into the RMBP plan.

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’s Information

World Bank Group UPI*

First Name*

Middle Name

Last Name*

Date of Birth*

Gender*

Email*

Please select where applicable to you and/or eligible family member*

Enrollment Details

Life Event*

Event Date*

Select Action to be performed*

Reason*

Specify the reason*

Pension categories for Ending Employment*

Pension categories for Spouse/Dep enrollment*

Lumpsum Pension- Direct billing: If you are not planning to receive the pension immediately after termination, you need to pay the prorated amount until June 30 to your MBP Administrator. The MBP Administrator will send us the SAP payment proof HR to proceed. In general, RMBP period runs from July to June, you will receive a mail from HR Operations during the month of June with the revised premium. If you would like to continue for the period July 01 to June 30 of the following year you have to pay the annual premium amount.

Monthly Pension- Monthly deduction: If you are planning to receive the pension immediately after termination, the premium will deduct from your monthly pension amount. There is no option to pay the prorated premium.

  • Please note that if you don’t have enough monthly pension to deduct the premium then you will be automatically moved to Direct billing and same will be communicated to your registered email id.
  • Also if you have enough monthly pension over a period of time, you will be moved to Monthly deduction and the same will be communicated to your registered email id.

Enrollment and RMBP options*

Family Details

Add eligible family member(s)

First Name*

Middle Name

Last Name*

UPI*

Relationship*

Gender*

Birth Date*

Place of Birth*

Nationality*

For Children Only

Is child under age 26?*

Family Details

Add eligible family member(s)

First Name*

Middle Name

Last Name*

UPI*

Relationship*

Gender*

Birth Date*

Place of Birth*

Nationality*

Enroll in RMBP?*

For Children Only:

Is child under age 26?*

Spouse and Dependent information

First Name*

Middle Name

Last Name*

Gender*

Nationality

Enroll in MBP?

For Children Only

Is child under age 26?

If you have children leaving your house hold as a result of this event, complete the section below.

First Name*

Middle Name

Last Name*

Gender*

Remove Dependent

Change in Enrollment – Remove Eligible Family  Member(s)

  • HR automatically ends medical insurance (MBP/MIP) coverage for dependent children on the last day of the month of the child's 26th birthday. Special provisions may apply if the child is handicapped on reaching the age of 25. Contact HR Operations several weeks before your child's 25th birthday to obtain the appropriate underwriting forms, which need to be completed by your child's physician.
  •  For reduction in medical insurance coverage, there must be consent from the dependent (or child’s other parent, if the child is a minor). The dependent must either sign this form or submit along with this form a copy of the e-mail from dependent confirming that they will be removed.
  •  A dependent ending MBP coverage maybe eligible for up to 36 months of unsubsidized RMBP Continuation. I certify by my signature below that I have notified all dependents) ending RMBP and of their entitlement to RMBP continuation. I further certify by my signature below that I am responsible for reimbursing the World Bank Group for any MBP claims paid on behalf of my dependents) after the end of my RMBP coverage date of my dependent(s).

First Name*

Middle Name

Last Name*

Reason*

Specify*

Effective Date*

Signature of Dependent

Date

Active Staff MBP Coverage: If this request ends coverage for a dependent spouse in the active staff MBP, the spouse must consent to the loss of coverage in writing below. A spouse losing MBP coverage may be eligible for up to 36 months of MBP continuation. The spouse can never be eligible for RMBP coverage.

Signature of Spouse

Printed Name

Date

Retiree Authorization and Signature

I certify by my signature below that, if applicable, I will give my former spouse/child all MBP continuation information, including the CMBP enrollment form so that my former spouse/child may apply for MBP continuation within the prescribed period of time (60 days from end of MBP coverage). I further certify by my signature that I am responsible for reimbursing the World Bank Group for any MBP claims paid on behalf of my former spouse/child after the end of the MBP coverage for my spouse/child.

Retiree/Surviving Spouse/Dependent Authorization and Signature

I certify by my signature below that, if applicable, I will give my former spouse/child all MBP continuation information, including the CMBP enrollment form so that my former spouse/child may apply for MBP continuation within the prescribed period of time (60 days from end of MBP coverage). I further certify by my signature that I am responsible for reimbursing the World Bank Group for any MBP claims paid on behalf of my former spouse/child after the end of the MBP coverage for my spouse/child.

I certify that the above statements are accurate and true to the best of my knowledge.  I understand the information I have provided will be given to the World Bank Group's insurance administrators, I must promptly advise the World Bank Group of changes in my RMBP eligibility. 
I authorize the World Bank Group to deduct my share of the monthly costs of the RMBP from my pension payments, if applicable.  If I am not in receipt of the monthly World Bank Group pension payments, I agree to pay for my RMBP premiums as specified by the World Bank Group.  I understand that I have the right to terminate my RMBP coverage at any given point of time.  I further understand that if I should cancel RMBP coverage, I will not be able to re-enroll at a later date.

Signature

Date

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.

As the MBP Administrator for ____________________ country, I understand that enrollment in the Retiree MBP plan must be made within 60 days from the date retiree/family member(s) become eligible.  I have checked and verified that the listed family members are eligible for the RMBP plan and that I have forwarded the digital copy to HR Operations of all necessary documents and kept a copy for records, filing and audit purposes.
Below a list of the document(s) submitted along with this form:

1. _____________________                                       6. _____________________

2. _____________________                                         7. ____________________

3. _____________________                                         8. ____________________

4. _____________________                                         9. ____________________

5. _____________________                                        10. ____________________

 

 

MBP Administrator's Name: _________________________ UPI:_____________  Date received: __________________

 

Signature: ________________________