Transcription of 2022 PEBB Employee Enrollment/Change (50-0400)
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2022 PEBB Employee Enrollment/Change (50-0400)
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. Subscribers must choose enrollment through one program or the other in medical and dental plans (PEBB Program), or medical, dental, and vision plans (SEBB Program). Choosing some PEBB plans and some SEBB plans is no longer or print clearly in blue or black ink and use all capital lettering in the spaces provided. Example: exclamation-triangle Remember to read and sign Section 6.
2022 PEBB Employee Enrollment/Change The 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.
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