Get the free PEBB Employee Enrollment/Change form (Medical only groups)
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2025 PEBB Employee Enrollment/Change form Use this form if you are unable to use Benefits 24/7 at benefits247.hca.wa.gov. The information written on this form replaces all enrollment/change forms
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How to fill out pebb employee enrollmentchange form
How to fill out pebb employee enrollmentchange form
01
Obtain the PEBB Employee Enrollment Change Form from the official PEBB website or your HR department.
02
Read the instructions carefully to understand what information is required.
03
Fill out your personal information at the top of the form, including your name, employee ID, and contact information.
04
Indicate the specific enrollment change you are requesting (e.g., adding a dependent, changing plans, etc.).
05
Provide details for the change, such as the name and relationship of the dependent being added.
06
Sign and date the form to certify that all information provided is accurate.
07
Submit the completed form to your HR department or the appropriate PEBB office as instructed.
Who needs pebb employee enrollmentchange form?
01
Employees who experience a qualifying life event (e.g., marriage, birth of a child, loss of other coverage).
02
Employees who wish to make changes to their health insurance coverage during open enrollment periods.
03
Employees who need to update their personal information, such as a name change or change of address.
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What is pebb employee enrollment change form?
The PEBB Employee Enrollment Change Form is a document used by employees to report changes in their eligibility or enrollment status in the Public Employees' Benefits Board (PEBB) health insurance plan.
Who is required to file pebb employee enrollment change form?
Employees who experience qualifying life events such as marriage, divorce, birth or adoption of a child, or loss of other health coverage are required to file the PEBB Employee Enrollment Change Form.
How to fill out pebb employee enrollment change form?
To fill out the PEBB Employee Enrollment Change Form, employees should provide their personal information, details about the qualifying event, and any changes in dependents or plans. It is important to follow the instructions provided on the form carefully.
What is the purpose of pebb employee enrollment change form?
The purpose of the PEBB Employee Enrollment Change Form is to officially update the employee's benefits enrollment based on life changes and to ensure they have the appropriate health coverage.
What information must be reported on pebb employee enrollment change form?
Information that must be reported includes the employee's name, employee ID, type of qualifying event, effective date of change, and details of any dependents being added or removed from coverage.
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