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RETIREE NOTICE OF ELECTION (NOE) R SOUTH ... - South …

REV. 2/4/2020 ORIGINAL TO PEBA COPY TO ENROLLEE You must also complete a Certification Regarding Tobacco Use form within 31 days of enrolling in health coverage and whenever the status of tobacco use changes for you or a dependent covered under your health Social Security number orBIN2. Last Name3. SuffixRETIREE NOTICE OF ELECTION (NOE) SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITYRSee Instructions - if completing by hand use black inkSelect OneRegular RetireeDisability RetireeELIGIBILITYENROLLEE INFOCOVERAGEMF4. First Name5. date of Birth (MM/DD/YYYY)10. Email Address9. Home Phone #7. Sex12. Mailing Address13. City14. State15. Zip Code16. County Code17. HEALTH PLAN (Refuse or select one plan and one level of coverage)PLANCOVERAGE LEVELS tandardRefuseSavings (not Medicare-eligible)TRICARE Supplement (not Medicare-eligible)Retiree19. VISION CARE (select one)Police RetireeSelect OneIndicate Record of Service (Attach Employment Record)8. Marital StatusWidowedSingleDivorcedMarriedSepara tedRetiree/SpouseRetiree/Child(ren)Famil yRetireeRetiree/SpouseRetiree/Child(ren) FamilyRefuse18.

Last Name. Date of Birth (MM/DD/YYYY) First Name. Incapacitated. Add (A) or Indicate Special Status Delete (D) Incapacitated Incapacitated. ... check the 5-14 year retiree block. If you initially became eligible for insurance on or after May 2, 2008, and you have less than 25 years service credit, check the 15-24 year retiree block. Check the

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Transcription of RETIREE NOTICE OF ELECTION (NOE) R SOUTH ... - South …

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South Carolina Retirement System Member …

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Step 8 Step 5 Step 6 Step 7 Member Access is the online resource that allows you, as a member of a retirement system administered by PEBA, to view and

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Prescription Drug Reimbursement / Coordination of Benefits Claim Form. An incomplete form may delay your reimbursement. See the back for instructions and complete all information.

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ACTIVE NOTICE OF ELECTION (NOE) - South Carolina

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Indicate Special Status. INSTRUCTIONS FOR COMPLETING THE ACTIVE NOTICE OF ELECTION (NOE) IF COMPLETING BY HAND, USE BLACK INK . You must also complete a . Certification Regarding Tobacco Use . form within 31 days of enrolling in health coverage and whenever the status of

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COBRA NOTICE OF ELECTION (NOE) C SOUTH CAROLINA …

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I understand my COBRA continuation coverage rights and responsibilities, as explained in the election notice and attachments provided to me. I also understand that the State reserves the right to alter benefits or premiums at any time to preserve the financial stability of the Plan.

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Certification Regarding Tobacco or E-cigarette Use SCPEBA 042020 Certification Regarding Tobacco or E-cigarette Use Check the appropriate box, sign and return to S.C. PEBA, 202 Arbor Lake Drive, Columbia, SC 29223.

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Benefits Administrator Manual SCPEBA 122021 | Expires 12312022 │ 13 This manual outlines the rules, regulations, policies and procedures of the S.C. Public Employee Benefit Authority (PEBA) and contains an abbreviated description of insurance benefits offered by or through PEBA. When determining benefits, the Plan of Benefits

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First Lienholder Authorization — This block must be signed by the first lienholder when adding a second lien. Checks may be accepted as payment. ... LIEN RELEASE SECTION — Enter the lienholder’s name as shown on title, the date of release, printed name of the lienholder’s agent, and signature of lienholder’s agent.

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