Transcription of 2022 PEBB Employee Enrollment/Change (50-0400) - …
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Page 1 of 121211 HCA 50-0400 (8/21)2022 PEBB Employee Enrollment/ChangeThe information written on this form replaces all Enrollment/Change forms previously submitted. Therefore, you must complete the entire form, including the dependent section for any children you want to continue to cover. Inaccurate, incomplete, or illegible information may delay coverage. Starting January 1, 2022, all members who are eligible for enrollment in both the PEBB Program and the School Employees Benefits Board (SEBB) Program are limited to enrolling in health plans through either the PEBB Program or the SEBB Program.
exclamation-triangle If Yes, please contact your payroll or benefits office for help. Starting January 1, 2022, all members are limited to enrolling in health plans through either the PEBB Program or the SEBB Program. Tobacco use premium surcharge
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