Get Pebtf 14

Filling out the Pebtf 14 form is an essential step for obtaining Adult Dependent Coverage under the Pennsylvania Employees Benefit Trust Fund. This guide will walk you through the completion of this document, ensuring you provide all necessary information accurately and effectively.

Follow the steps to complete the Pebtf 14 form smoothly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the subscriber information section. Begin by entering your Social Security Number, full name (first, middle initial, last), address (including street, city, state, and zip code), and telephone numbers for both home and work.
3. In the section for applying for Adult Dependent Coverage, make sure to indicate whether the adult dependent is enrolled in the same health plan as the subscriber. Note that certification is required annually, and ensure that you are prepared to continue making monthly payments for coverage.
4. Complete the Adult Dependent Information section by providing the dependent's Social Security Number, name, and whether their address is the same as the subscriber's. If different, list their address in the relevant fields.
5. Enter the dependent's date of birth, relationship to the subscriber, and the effective date of coverage. Be attentive to any instructions regarding what qualifies as a qualifying event for coverage.
6. Answer the additional questions regarding the dependent's marital status, whether they have dependents, and their educational status. Indicate if they are enrolled in any other health insurance or government health care benefits programs.
7. Review the authorization for application for enrollment section carefully before signing. This section details your understanding of participation conditions and responsibilities regarding subrogation.
8. Make sure to sign and date both the subscriber's and the adult dependent's signature fields.
9. Once all fields are completed accurately, save your changes. You can then download, print, or share the Pebtf 14 form as needed.

Complete the Pebtf 14 form online today to ensure your adult dependent's coverage.