RETIREE MEDICAL PLAN ELECTION FORM Please sign and date below: Date: Retiree Signature: Date: Spouse/Surviving Spouse Signature: If you are an authorized representative, you must sign above and provide the following information: Name: _______________________________________________ Address: ______________________________________________ Phone Number: ________________________________________ Relationship to Retiree: _________________________________ Please return signed election form to: Amwins Group Benefits 50 Whitecap Drive, North Kingstown, RI 02852 For Customer Service, please call: 1-888-883-3757 Monday through Friday, 8:00 AM to 8:00 PM EST CW