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E. Date: Birth Date: National Medical Support Notice (NMSN) Date: Other reason (describe): Date: Adoption or placement for adoption Date: List only dependents added by this change. Check plan selections if applicable. Do not list current dependents. Relationship Key: SP Spo.

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PEBB designs, contracts and administers a program of benefits for the state as the employer and state employees. The benefits include medical and dental coverage; life, accident, disability and long-term care insurance; and flexible spending accounts.

Double coverage is a benefit available to public employees whose spouse or domestic partner is also eligible for PEBB or OEBB benefits. In these cases, people can use each other's healthcare plans to cover out of pocket costs or receive a opt out if they choose to forgo double coverage.

An eligible employee means an employee of a PEBB participating organization, and state officials in an exempt, unclassified, classified, or management position, who are expected to work at least 90 days and work at least half time or in a position classified as job share.

Spouse/Domestic Partner Surcharge - $50/month if spouse/domestic partner waives coverage in another employer's group plan (non-PEBB plan) in favor of coverage through PEBB.

You are eligible for PEBB benefits upon employment if your employer anticipates you will work: An average of at least 80 hours per month. For at least eight hours in each month. For more than six consecutive months.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232