Get the free peia surviving enrollment form - peia wv

I State of West Virginia Public Employees Insurance Agency SD Surviving Dependents - Health Benefits Enrollment Form Complete this form to enroll for or continue PEIA health insurance coverage as a surviving dependent.

How to fill out peia surviving enrollment form

How to fill out peia surviving enrollment form:

1. Obtain the peia surviving enrollment form from your employer or the PEIA website.
2. Carefully read the instructions on the form to understand the information required and any supporting documents needed.
3. Fill in your personal information accurately, including your full name, date of birth, social security number, and contact details.
4. Provide details about the deceased individual, such as their name, date of birth, and social security number.
5. Indicate the type of coverage you are enrolling for, such as medical, dental, or vision, and provide any additional information requested.
6. If you have a qualifying event, such as marriage or loss of other insurance coverage, provide the necessary documentation to support the enrollment.
7. Sign and date the form, and ensure that any required witnesses or notaries also sign and provide their contact information.
8. Submit the completed form and any supporting documents to the appropriate entity, such as your employer's human resources department or the PEIA office.

Who needs peia surviving enrollment form:

1. Individuals who have lost their spouse or dependent and need to enroll in PEIA coverage as a surviving member.
2. Employees or retirees who were previously covered under a family plan and need to update their coverage to reflect the loss of a spouse or dependent.
3. Individuals who have recently married and need to add their new spouse to their PEIA coverage.

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What is peia surviving enrollment form?

PEIA Surviving Enrollment Form is a form used by the Public Employees Insurance Agency (PEIA) to enroll surviving dependents of deceased employees in their health insurance coverage.

Who is required to file peia surviving enrollment form?

The surviving dependents of deceased employees are required to file the PEIA Surviving Enrollment Form.

How to fill out peia surviving enrollment form?

To fill out the PEIA Surviving Enrollment Form, the surviving dependents need to provide their personal information, such as name, date of birth, address, and relationship to the deceased employee, along with any necessary documentation to support their eligibility.

What is the purpose of peia surviving enrollment form?

The purpose of the PEIA Surviving Enrollment Form is to ensure that the surviving dependents of deceased employees have access to health insurance coverage through PEIA.

What information must be reported on peia surviving enrollment form?

The PEIA Surviving Enrollment Form requires the reporting of personal information of the surviving dependents, such as name, date of birth, address, and relationship to the deceased employee. Additionally, any necessary documentation to support their eligibility may need to be reported as well.