Get Pebb Opt Out Form

Filling out the Pebb Opt Out Form online is an important step for users wishing to make changes to their medical and dental insurance. This guide provides clear instructions for each section of the form, ensuring a smooth and efficient process.

Follow the steps to successfully complete the Pebb Opt Out Form.

1. Click the ‘Get Form’ button to access the Pebb Opt Out Form and open it in your online editor.
2. Begin by completing Section A, which requires employee and subscriber information. Ensure that all fields are filled out accurately, including name, date of birth, ID number, and contact information.
3. Proceed to Section B to provide information related to your qualified status change (QSC). Here, you will select the type of change you are requesting, such as adding or removing a dependent. Make sure to enter the QSC date; processing will not begin without this date.
4. In Section B.3, certify that your dependent children between the ages of 19 to 24 meet the eligibility requirements. This certification is crucial for the processing of dependents’ enrollments.
5. If applicable, complete Section C to provide coordination of benefits information if you or your dependents have other coverage. Attach the necessary documents, such as Medicare cards, where required.
6. Finally, in Section D, sign and date the form to authorize your requests. Remember to retain a copy for your records before submitting the form to the appropriate address based on your employment status.
7. Once all sections are completed and reviewed, save the changes and choose to download, print, or share the completed form as needed.

Complete your Pebb Opt Out Form online today for a hassle-free experience.