Get Change In Status Peia 2009-2025

Filling out the Change In Status Peia form is essential for users wishing to update their coverage status. This guide provides detailed instructions to help you navigate the process smoothly and effectively.

Follow the steps to complete the Change In Status Peia form

1. Click ‘Get Form’ button to access the Change In Status Peia form, and open it in your preferred online editor.
2. Begin by entering your name, including your first name, last name, and middle initial. Provide your completed street address, including city, state, and zip code. Check the box if there is a new address.
3. Fill in your county of residence and social security number. Provide your home and work phone numbers, and your job title.
4. Indicate your participation in the IRS Section 125 Premium Conversion Plan by checking ‘Yes’ or ‘No’.
5. Choose the type of status change you are making by marking the appropriate box, such as Name Change, Add or Remove Dependents, or Change in Health Coverage.
6. If adding or removing dependents, fill in the required details for each dependent, including their name, relationship, sex, birth date, and social security number.
7. Specify the reason for the status change and provide any necessary documentation to support your change.
8. Read the certification statement, and confirm by providing the date of the event. Sign and date the form to validate your request.
9. Follow the instructions on page 2 for any further required information, including dependent addresses, COBRA information, and tobacco or living will affidavits.
10. Save your changes, and once you have completed all sections, download, print, or share the form as needed.

Complete your Change In Status Peia form online today!