Retirement Healthcare Program Claims Activation Form Page 1 of 2 TA CRH/OTCMNTRHSP F11292 (2/24) 1. ACCOUNT HOLDER (FORMER EMPLOYEE) INFORMATION Please print using black ink. Title First Name M.I. Last Name Suffix Social Security Number/ Taxpayer Identification Number Date of Birth (mm/dd/yyyy) Marital Status Gender / / Single Married Male Female Contact Telephone Number Extension Email Address Retirement Healthcare Account Number Employer Name W