Get Pa Pebtf-36 2023-2025

The PA PEBTF-36 form is essential for verifying eligibility for health benefits under the Pennsylvania Employees Benefit Trust Fund (PEBTF) for employees hired on or after August 1, 2003. This guide will walk you through the process of filling out the form online, ensuring all required information is completed accurately.

Follow the steps to complete the PA PEBTF-36 form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Begin by providing the commonwealth employee's name in the designated field. Ensure the name matches official documents for accuracy.
3. Input the commonwealth employee number in the appropriate section. This information is essential for identification purposes.
4. Fill in the commonwealth employee's date of birth in the format mm/dd/yyyy. This helps to verify identity and age.
5. Enter the spouse's name in the next field, ensuring it aligns with legal documents, for verification.
6. Provide the spouse's date of birth, also formatted in mm/dd/yyyy. Accurate details are vital for eligibility assessment.
7. Indicate whether the spouse is employed by selecting either 'Full-Time' or 'Part-Time' as applicable. If the spouse is not employed, select 'No'.
8. Specify if the spouse is retired by marking the appropriate option. This is crucial for confirming eligibility.
9. Affirm the accuracy of the information by signing and dating the employee's signature field. This confirms that all details provided are complete and correct.
10. The next section must be completed by an authorized representative of the spouse’s employer. They will provide the employer's name and answer eligibility questions.
11. The employer's representative should indicate whether the spouse is eligible for health insurance, providing relevant dates for eligibility and enrollment.
12. If applicable, the employer representative must sign and date the form to verify the information provided.
13. Finally, review the completed form for any errors or omissions. Save your changes, then download, print, or share the form as necessary.

Complete your PA PEBTF-36 form online today to ensure your health benefits are verified promptly.