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Public Employees Benefits Board (PEBB) Program ...
Reset Public Employees Benefits Board (PEBB) Program Underwritten by Standard Insurance Company Long Term Disability (LTD). enrollment / change form Employees Please type or print clearly in ink Personnel, payroll, or Benefits office staff If you do not wish to enroll in optional LTD coverage, complete Sections 1 & 2. Review Sections 1 3 for completeness and If you wish to enroll in or change optional LTD coverage, complete Sections 1 & 3. Your accuracy, and complete Section 4. personnel, payroll, or Benefits office will automatically enroll you in Part A (Basic) LTD Do not send the form to Standard Insurance coverage. Company or the PEBB Program . Return this form to your personnel, payroll, or Benefits office.
SI 7533D-377661 Page 1 of 1 (6/15) Public Employees Benefits Board (PEBB) Program Underwritten by Standard Insurance Company . Long Term Disability (LTD) Enrollment/Change Form
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