Get Pebtf Annuitant Change Form (pebtf-10). Pebtf Annuitant Change Form

The PEBTF Annuitant Change Form (PEBTF-10) is essential for updating your health benefits record. This guide provides clear and detailed instructions for filling out the form correctly and efficiently, ensuring that your changes are processed smoothly.

Follow the steps to fill out the PEBTF Annuitant Change Form.

1. Press the ‘Get Form’ button to open the PEBTF Annuitant Change Form (PEBTF-10) in your preferred online editor.
2. Begin with the Annuitant Demographics section. Enter your name (Last, First, Middle Initial), home and alternate telephone numbers, street address, city, state, county name, and zip code accurately.
3. Indicate the changes needed to your health benefits record by checking the applicable boxes. Options include opting-out of coverage or making changes for members and dependents for medical or Rx coverage. Ensure to provide any effective dates and reasons if removing or adding dependents.
4. Complete the Annuitant / Dependent Enrollment Data section with all required details. Fill in the names of your dependents, their dates of birth, gender, and social security numbers, as well as their Medicare information if applicable.
5. Choose the appropriate health care plan options for each person listed. This includes deciding between non-Medicare and Medicare plan options.
6. In the Comments section, note any additional information that may be relevant to your changes.
7. Review your application. Once you confirm that all information is accurate, provide your signature and the date to authorize the application.
8. Finally, save your changes and export the completed form. You may then choose to download it for your records, print it out, or share it as necessary.

Complete your PEBTF Annuitant Change Form online today!