Get Or 107-024 2008-2026

Filling out the OR 107-024 affidavit of dependency form is essential for requesting benefit plan coverage for eligible children. This guide provides clear, step-by-step instructions to help you navigate the online form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the affidavit of dependency form and open it in the available editor.
2. In Section A, complete each item related to your employee information, including your last name, first name, middle initial, date of birth, identification number, gender, mailing address, residence address, and contact information.
3. Move to Section B and fill out the child information. This includes the child's last name, first name, middle initial, date of birth, residential address, relationship to you, identification number, and the date of your responsibility for their support.
4. In Section C, read through the declaration of dependent eligibility carefully. Check the eligibility criteria that applies to the child, confirming that they meet the guidelines for dependency, including age and living arrangements.
5. Proceed to Section D to provide your signature and authorization. Make sure to notarize the document, sign, and date it in the designated areas.
6. After completing the form, ensure you make a copy for your records. Submit the notarized form along with the required PEBB enrollment or update form to the appropriate agency or university payroll or benefits office.
7. If you are a self-pay participant or under COBRA, send the completed forms to BenefitHelp Solutions at the provided address. Ensure that you submit to the correct address to avoid processing delays.
8. Finally, review all your entries for accuracy before saving your changes and optionally downloading, printing, or sharing the form as needed.

Complete your documents online to ensure timely processing of your benefits.