Get the free Retiree Enrollment/Change Form (PEBTF-9)

Retired Employees Health Program Annuitant Enrollment Form Title: Mr. Mrs. Dr. Ms. Name (Last, First, MI) 1. Annuitant Account Data Street Address Gender (M/F) City State Zip Code County Name Home

How to fill out retiree enrollmentchange form pebtf-9

How to fill out retiree enrollment change form pebtf-9:

1. Start by providing your personal information, such as your name, address, date of birth, and social security number.
2. Indicate your current retiree status by checking the appropriate box. This could include being an annuitant, a surviving spouse, or a disabled retiree.
3. If you have any dependents that need to be included in the enrollment change, provide their names, dates of birth, and their relationship to you.
4. Specify the type of enrollment change you are making by checking the relevant box. This could involve adding or removing dependents, changing health plan coverage, or updating contact information.
5. If you are changing your health plan coverage, indicate the name of the health plan you are currently enrolled in and the new plan you wish to switch to.
6. If you have any additional comments or explanations regarding your enrollment change, there is a designated space provided for you to write them down.
7. Review all the information you have provided on the form to ensure its accuracy and completion.
8. Sign and date the form to certify that the information you have provided is true and correct.
9. Keep a copy of the filled-out form for your records before submitting it to the relevant authority.

Who needs retiree enrollment change form pebtf-9:

1. Retirees who wish to make changes to their current enrollment status, such as adding or removing dependents, changing health plan coverage, or updating contact information.
2. Surviving spouses of retirees who need to make changes to their enrollment status.
3. Disabled retirees who require adjustments to their current enrollment.

Note: It is advisable to consult the specific guidelines provided by the Pennsylvania Employees Benefit Trust Fund (PEBTF) or the relevant authority to ensure accurate completion of the retiree enrollment change form pebtf-9, as procedures may vary.

For pdfFiller’s FAQs

What is retiree enrollmentchange form pebtf-9?

Retiree enrollmentchange form pebtf-9 is a form used by retirees to make changes to their enrollment in the Pennsylvania Employees Benefit Trust Fund (PEBTF).

Who is required to file retiree enrollmentchange form pebtf-9?

Retirees who wish to make changes to their enrollment in PEBTF are required to file retiree enrollmentchange form pebtf-9.

How to fill out retiree enrollmentchange form pebtf-9?

Retirees can fill out retiree enrollmentchange form pebtf-9 by providing accurate information about the changes they want to make to their enrollment.

What is the purpose of retiree enrollmentchange form pebtf-9?

The purpose of retiree enrollmentchange form pebtf-9 is to allow retirees to update their enrollment information with PEBTF.

What information must be reported on retiree enrollmentchange form pebtf-9?

Retirees must report any changes they want to make to their enrollment information, such as adding or removing dependents.

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