Peia Change In Status Form - State Of West Virginia

Download a blank fillable Peia Change In Status Form - State Of West Virginia in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Peia Change In Status Form - State Of West Virginia with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

State of West Virginia • Public Employees Insurance Agency

Change in

Change-In-Status Form

Status

Complete this form to change the status of your coverage. Complete all sections as appropriate except the Employer Information on page 2 and return

the form to your benefit coordinator.

(First)

(MI)

(Generation: Jr., Sr., etc.)

Social Security Number

Name (Last)

Check if New Address

County of Residence

Home Phone

Street Address

(

)

State

Zip

Work Phone

City

Job Title

(

)

Do you participate in the IRS Section 125 Premium Conversion Plan sponsored by PEIA, if available?

YES

CHANGE TYPE Please indicate the status change you are making:

Name Change: Policyholder c Dependent c (Last)______________________________________ (First)____________________________ (MI)________

001

002

Transfer employee's premium billing from employer account # _________________ to account # _________________ within the same agency

003

Add Dependents to: (Mark your choice) c Health c Dependent Optional Life Insurance (check one) c Plan 1 c Plan 2 c Plan 3 c Plan 4 c Plan 5

(Complete dependent information below. If not in the initial enrollment period, Evidence of Insurability is required for life insurance.)

004

Remove Dependents from: (Mark your choice and complete dependent information below) c Health c Dependent Optional Life Insurance

Change in health coverage: From: (Plan Name)_____________________________________ To: (Plan Name) _______________________________________

005

006

Add Health Coverage:

c PEIA PPB Plan A c PEIA PPB Plan B c PEIA PPB Plan C

c PEIA PPB Plan D

c Health Plan HMO Plan A c Health Plan HMO Plan B c Health Plan PPO

007

Drop Health Coverage. Keep life insurance ONLY. This terminates health coverage for policyholder and all dependents.

Tobacco Status Change.

008

Advance Directive/Living Will Affidavit Change.

009

Birth Date

Social Security Number

Address

Relationship

Sex

Dependent Name (Last, First, MI, Generation)

(if different from above)

(Circle One)

(mm/dd/yyyy)

(Circle One)

Status Change Reason. Policyholder must provide documentation for every type of status change. See attached memo for details.

Change from full-time to part-time

employment or vice versa for

Marriage

Death of spouse or dependent

employee, spouse or dependent

Beginning or end of spouse's or

Open Enrollment

Divorce

dependent's employment

Other (please specify): ____________

Significant change in health coverage

______________________________

due to spouse's or dependent's

Birth of Child

______________________________

employment

Unpaid leave of absence by

Adoption

employee, spouse or dependent

I certify that on _____/_____/_____(date of event) I incurred the status change marked above, and I, therefore, wish to change my plan benefits as

indicated. I understand that the change requested must be consistent with the event. I further understand that I am required to provide documentation of this

event to the WV Public Employees Insurance Agency.

This form is continued on page 2. You must complete and return both pages of the form for it to be valid. Please continue.