Enrollment Form

If applying during Annual Enrollment – The effective date of your coverage will be January 1, if this form is completed in full and signed by December 31. To ensure you receive your new Medical and Prescription Drug cards by January 1, your completed form should be submitted by mid-November. Your initial premium is due the 1^st of the month, for the upcoming month’s coverage. Your initial premium billing statement will be sent to you once your enrollment has been processed.

If applying when turning 65 – The effective date of your coverage will be the 1st of the month following the signature date on this form, but not prior to the month in which you turn 65. If your birthday is on the 1st of the month, your coverage can be effective on the 1st of the month prior to your 65th birthday.

If you use a P.O. Box as your mailing address and you are enrolling in the Medical/Prescription Drug Plan, we need to have your physical street address. Your P.O. Box number will be used as your mailing address. Please provide this information in the section noted on the last page of this enrollment form.

Step 1 of 3

Former Delta Employee Information

*Please note: Former Delta Employee information is required, regardless of whether the applicant is the Former Employee, their Spouse, or a Former Spouse.

Name(Required)

First Last

Social Security #(Required)

Delta PPR #

Requested Coverage Effective Date(Required)

MM/DD/YYYY (Note: Coverage must start as of the first of the month, and can not be a past date)

Date of Birth(Required)

Gender(Required)

Male

Female

Phone(Required)

Medicare ID Number

Part A Effective Date

Part B Effective Date

Relationship to Former Employee(Required)

If you, the applicant, are the Former Employee or Spouse, are you enrolling for both yourself and your spouse?(Required)

Yes

Spouse Information

Name(Required)

First Last

Social Security #(Required)

Requested Coverage Effective Date(Required)

MM/DD/YYYY (Note: Coverage must start as of the first of the month, and can not be a past date)

Date of Birth(Required)

Gender(Required)

Male

Female

Medicare ID Number

Part A Effective Date

Part B Effective Date

*Please note: Delta Applicant Information is required regardless if the Delta retiree is under age 65 or not enrolling in coverage.

Insurance Trust for Delta Retirees Benefit Plan Election

To view 2021 monthly premium rates click here. To view 2022 monthly premium rates click here. See the Benefits & Resources Guide for additional information.
Please indicate below the coverage(s) in which you wish to enroll.

Health Plan Choice(Required)

VA or TRICARE

Check if you have a Prescription Drug plan through the VA or TRICARE

*If you have VA or TRICARE coverage, you may elect Medical only coverage. Proof of VA coverage is required to remove the Prescription Drug plancoverage. Please call the Retiree Service Center at 1-877-325-7265, Option 1, for information required to elect Medical only coverage.

Included in your Medical and Prescription Drug Plan cost is a fee to cover reasonable administrative/operating expenses of the Trust.

Dental Plan Information – Choose the appropriate selection from the drop down

DELTA Dental

Dental Plan Choice(Required)

**Dental Plan cost for Dental only or Dental/Vision only coverage includes a $2.00 fee for administrative/operating expenses of the Trust.

Vision Plan Information – Choose the appropriate selection from the drop down

Vision Plan Choice(Required)

Insurance Trust for Delta Retirees Spouse Benefit Plan Election

Spouse Health Plan Choice(Required)

VA or TRICARE

Check if you have a Prescription Drug plan through the VA or TRICARE

Included in your Medical and Prescription Drug Plan cost is a fee to cover reasonable administrative/operating expenses of the Trust.

Spouse Dental Plan Information – Choose the appropriate selection from the drop down

DELTA Dental

Spouse Dental Plan Choice(Required)

**Dental Plan cost for Dental only or Dental/Vision only coverage includes a $2.00 fee for administrative/operating expenses of the Trust.

Spouse Vision Plan Information – Choose the appropriate selection from the drop down

Spouse Vision Plan Choice(Required)

Email Address

Please provide your email address. The Trust communicates with Members via email to relay information about the Trust Benefit Plans and Trust Board activities. Your email will not be shared with any outside party.

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If you are an authorized representative, please provide the following information:

Name

First Last

Address(Required)

Street Address Address Line 2 (Unit, Apt.) City State / Province / Region ZIP / Postal Code

Phone

Relationship to Applicant

About the Trust Administrative / Operating Expenses

Reasonable administrative/operating expenses of the Trust can include by example: printing and mailing of Member communication materials, legal, audit, accounting, reimbursement of travel and other appropriate expenses of Trust Board members, and other obligations of the Trust undertaken for the benefit of Members. No compensation is paid, by the Trust or by any other organization, to Trust Board Members for their work.

Eligibility Attestation for Enrollment

To enroll in the Insurance Trust for Delta Retirees, Inc. Benefit Plan (the “Plan”), you must meet specific eligibility criteria, which are outlined below. To verify your eligibility, please complete the following attestation below certifying that you meet the applicable requirements for eligibility under the Plan. Your enrollment application will not be processed unless your eligibility has been attested to. If you have any questions regarding the eligibility requirements described below, please contact the ITDR Retiree Service Center. Customer Services Representatives are available to answer your questions at 1-877-325-7265, Option 1, Monday through Friday, 7:30 am – 8:00 pm, CST.

I am a former employee, survivor, spouse, or former spouse of one or more of the following entities:

Delta Air Lines, Inc. (“Delta”);
a Delta subsidiary; or
an entity (or its subsidiary) acquired by Delta, or merged with Delta, where Delta is the surviving entity and I retired prior to the effective date of the acquisition or merger. (This includes pre-merger Northwest and Republic retirees.)

I worked for this entity described above during the following period:
(Fill in the applicable dates below. If you have multiple periods of employment, please include information for all periods.)

Employment Details(Required)

Employing Entity

Start Date

Termination or Retirement Date

I attest that the above information is true and accurate to the best of my knowledge as of the date that I sign and submit this attestation. I acknowledge and understand that the Insurance Trust for Delta Retirees, Inc. is relying on my representation and attestation in connection with obtaining insurance. I further acknowledge and understand that if the information contained in this attestation is later found not to be accurate, I may be terminated from participation in the Plan (including retroactively to the date of this attestation).

Name(Required)

First Last

Date(Required)

Applicant Signature(Required)

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Name

This field is for validation purposes and should be left unchanged.

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Former Delta Employee Information

Spouse Information

Insurance Trust for Delta Retirees Benefit Plan Election

Dental Plan Information – Choose the appropriate selection from the drop down

DELTA Dental

Vision Plan Information – Choose the appropriate selection from the drop down

Insurance Trust for Delta Retirees Spouse Benefit Plan Election

Spouse Dental Plan Information – Choose the appropriate selection from the drop down

DELTA Dental

Spouse Vision Plan Information – Choose the appropriate selection from the drop down

Email Address

Please read

About the Trust Administrative / Operating Expenses

Eligibility Attestation for Enrollment