Get the free PEBB retiree change form (form E) 2025

2025 PEBB Premium Surcharge Attestation Change Form Use Benefits 24/7 at benefits247.hca.wa.gov or this form to report a change that affects your premium surcharge for tobacco use or spouse or stateregistered

How to fill out pebb retiree change form

How to fill out pebb retiree change form

1. Obtain the PEBS retiree change form from the official website or human resources department.
2. Fill in your personal information at the top of the form, including your name, address, and contact information.
3. Indicate whether you are making a change to your health insurance, dental insurance, or both.
4. Provide the details of the changes you are requesting, such as adding or removing a dependent.
5. If applicable, include any required documentation, such as proof of dependency or marriage certificate.
6. Review the completed form for accuracy and completeness.
7. Sign and date the form to certify that the information provided is true.
8. Submit the form to the designated office by the specified deadline, either in person or by mail.

Who needs pebb retiree change form?

1. Any retired employee who wishes to make changes to their health or dental insurance benefits under the PEBB (Public Employees Benefits Board) program.

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What is pebb retiree change form?

The PEBB retiree change form is a document that allows retirees from the Public Employees Benefits Board (PEBB) to update their health coverage, enrollment status, or personal information related to their benefits.

Who is required to file pebb retiree change form?

Retirees who need to change their benefits or personal information, such as address changes or dependent eligibility updates, are required to file the PEBB retiree change form.

How to fill out pebb retiree change form?

To fill out the PEBB retiree change form, you need to provide your personal information, specify the changes you wish to make, and submit the completed form to the appropriate benefits administration office.

What is the purpose of pebb retiree change form?

The purpose of the PEBB retiree change form is to ensure that retirees can accurately update their health benefits and coverage options to reflect their current status and needs.

What information must be reported on pebb retiree change form?

The information that must be reported includes the retiree's identification details, the nature of the change (e.g., address, dependent information), and any relevant documentation supporting the request.