Get Pebtf Attestation

The Pebtf Attestation is an important document that allows dependents under age 26 to continue health coverage. This guide will provide clear, step-by-step instructions on how to complete the form online to ensure your dependent maintains their eligibility for coverage.

Follow the steps to successfully complete the attestation online.

1. Press the ‘Get Form’ button to access the Pebtf Attestation and open it for editing.
2. Begin by filling out the subscriber information. Enter the last four digits of your Social Security number, your full name (first, middle initial, last), and your address including street, city, state, and zip code. Additionally, provide your date of birth.
3. Proceed to the dependent information section. Enter the last four digits of your dependent's Social Security number and their full name. Indicate if the dependent's address is the same as yours. If it differs, provide their address details.
4. Provide your dependent's telephone number, including home and work phone numbers. Enter your dependent's date of birth.
5. Answer questions regarding your dependent's eligibility for other employer-sponsored health coverage. If applicable, provide the effective date of that coverage and the name and address of the employer.
6. Review all the information entered to ensure accuracy. Once confirmed, sign the certification section to confirm the information is correct to the best of your knowledge and authorize the continuation of coverage.
7. Date your signature and prepare to submit the completed form. Ensure that it is returned to the PEBTF within 30 days to prevent termination of coverage.
8. Save your changes to the form. You can download, print, or share the completed Pebtf Attestation as needed.

Complete the Pebtf Attestation online now to secure health coverage for your dependent.