2019 Eligible Retiree and Dependent Enrollment

Transcription

1 Print Reset 2019 Eligible Retiree and Dependent ment Offie use only Approved by: Approved date: Effetive date: See the Summary Plan Desription for more information on benefits at Submit ompleted form to BenefitHelp Solutions, PO Box 40548, Portland, OR or Fax to or Keep a opy of your benefit forms for your reords. Any alteration of this form may result in it being ineffetive. I am enrolling as New retiree (retirees have 30 days from the loss of ative employee overage to enroll in PEBB retiree overage) Retirement Date: Eligible by relationship to PEBB retiree PEBB retiree name: Date of birth: New retiree orreting enrollment eletions Contat information (You must omplete all fields) PEBB benefit number (P########), OR#, University ID or Lottery ID Last name Ageny M F Chek if new address Contat address Apartment # City Residene ZIP ode Work ZIP ode Work DDate of birth () State ZIP Personal (optional) Work phone Home phone (optional) Are you Mediare eligible? (this may effet enrollment) Yes If yes, please ontat BenefitHelp Solutions at No Are you serving or did you ever serve in the military? No Yes Do you authorize PEBB to send your name and address to Oregon Department of Veteran s affairs (ODVA) No Yes for the purpose of reeiving benefit information? Ethniity: Hispani Rae: Asian Non-Hispani/Non-Latino Amerian Indian/Alaska Native Native Hawaiian/Other Paifi Islander Unknown Refuse Blak/Afrian Amerian White Page 1 of 5 Unknown Refuse Other

2 Family overage (List all eligible family members you want to provide overage for in Attah additional dependent sheet if neessary.) Spouse/Domesti Partner Last name Relationship M F Spouse Partner Med Den Vision Is this dependent Mediare eligible? No Yes This may effet enrollment. If yes all BenefitHelp Solutions at Ethniity: Hispani Asian Rae: Non-Hispani/Non-Latino Amerian Indian/Alaska Native Native Hawaiian/Other Paifi Islander Unknown Refuse Blak/Afrian Amerian White Unknown Refuse Other If you listed a Domesti Partner, mark the type of Domesti Partnership (Affidavits need to be submitted along with the enrollment form.) Registered Certifiate of Domesti Partnership (Copy not required) You have a registered ertifiate issued to you and your same sex partner, by an Oregon ounty lerk. PEBB Domesti Partner Affidavit is a partnership between an eligible employee and an individual of the opposite sex, or same sex without a Certifiate of Registered Domesti Partnership. Eligible dependent hildren (List the eligible hildren you want to provide overage for in Attah a separate sheet if neessary.) Required affidavits and appropriate legal douments for hild by affidavit or grandhild need to be submitted along with your enrollment form. Note: BenefitHelp Solutions will not proess the enrollment for the individual if doumentation has not been submitted. Dependent Partner s hild Grandhild by affidavit (both parent and grandhild are required to be Child Step Child Child by affidavit (inludes, but not limited to: foster hild and hild plaed for adoption or grandhild. When adoption is final provide paperwork to your payroll/hr to have status hanged to hild) Is this dependent Mediare eligible? No Yes This may effet enrollment. If yes all BenefitHelp Solutions at Ethniity: Rae: Hispani Asian Non-Hispani/Non-Latino Amerian Indian/Alaska Native Native Hawaiian/Other Paifi Islander Unknown Refuse Blak/Afrian Amerian White Page 2 of 5 Unknown Refuse Other

3 Partner s hild Grandhild by affidavit (both parent and grandhild are required to be Dependent Child Step Child Child by affidavit (inludes, but not limited to: foster hild and hild plaed for adoption or grandhild. When adoption is final provide paperwork to your payroll/hr to have status hanged to hild) Is this dependent Mediare eligible? No Yes This may effet enrollment. If yes all BenefitHelp Solutions at Non-Hispani/Non-Latino Unknown Refuse Ethniity: Hispani Asian Amerian Indian/Alaska Native Blak/Afrian Amerian Rae: Native Hawaiian/Other Paifi Islander White Unknown Refuse Other Partner s hild Grandhild by affidavit (both parent and grandhild are required to be Dependent Child Step Child Child by affidavit (inludes, but not limited to: foster hild and hild plaed for adoption or grandhild. When adoption is final provide paperwork to your payroll/hr to have status hanged to hild) Is this dependent Mediare eligible? No Yes This may effet enrollment. If yes all BenefitHelp Solutions at Non-Hispani/Non-Latino Unknown Refuse Ethniity: Hispani Asian Amerian Indian/Alaska Native Blak/Afrian Amerian Rae: Native Hawaiian/Other Paifi Islander White Unknown Refuse Other Partner s hild Grandhild by affidavit (both parent and grandhild are required to be Dependent Child Step Child Child by affidavit (inludes, but not limited to: foster hild and hild plaed for adoption or grandhild. When adoption is final provide paperwork to your payroll/hr to have status hanged to hild) Is this dependent Mediare eligible? No Yes This may effet enrollment. If yes all BenefitHelp Solutions at Non-Hispani/Non-Latino Unknown Refuse Ethniity: Hispani Asian Amerian Indian/Alaska Native Blak/Afrian Amerian Rae: Native Hawaiian/Other Paifi Islander White Unknown Refuse Other Page 3 of 5

4 Medial plans/dental plans (Some plans have speifi servie areas and may not be available to you, be sure to review plan availability for your area.) Medial Full time Part time Kaiser Dedutible (Kaiser vision inluded with full time plan) Kaiser HMO (Kaiser vision inluded with full time plan) Moda Summit Dental Full time Part time Kaiser Permanente Delta Premier Delta PPO N/A Moda Synergy Willamette Dental N/A PEBB Statewide PPO Providene Choie I Deline all Dental Plan ment Vision plan VSP Basi Plan VSP Plus Inludes the Basi Plan and PLUS additional benefits I Deline all VSP ment Tobao use (If you enroll in a Medial plan and do not omplete this Setion a tobao surharge ($25.00 per partiipant and $25.00 for spouse/partner enrolled in medial) will be added to your monthly premium.) Chek one box: I urrently use tobao and, my spouse/domesti partner urrently does not use tobao. ($25) I urrently do not use tobao, and my spouse/domesti partner urrently uses tobao. ($25) Both my spouse/domesti partner and I urrently use tobao. ($50) Both my spouse/domesti partner and I urrently do not use tobao. ($0) I urrently use tobao and do not have a spouse/domesti partner overed in PEBB. ($25) I urrently do not use tobao and do not have a spouse/domesti partner overed in PEBB. ($0) I do not enroll in PEBB medial plans. My or My spouse s or domesti partners provider advised not to quit using tobao (Medial Waiver). ($0) Page 4 of 5

5 Other spouse/partner employer group overage (If you enroll in a medial plan and over a spouse or partner you need to omplete this setion or a surharge will be added to your monthly premium.) When your spouse or domesti partner is enrolled in your PEBB medial overage and has aess to medial overage from their employer s sponsored group plan (i.e., a non- State of Oregon) but does not enroll for it, $50 will be added to your monthly PEBB premium. Chek one box: My spouse/domesti partner has PEBB overage as an eligible employee (Inludes a spouse who enrolls in Opt Out). ($0) My spouse/domesti partner has other employer group overage available and enrolls for that overage. ($0) My spouse/domesti partner has other-employer group overage available, but does not enroll in that overage and is enrolled in PEBB overage. ($50) My spouse/domesti partner does not have other-employer group overage available. ($0) I do not over a spouse or domesti partner in a PEBB medial plan. ($0) Partiipant signature and authorization I delare that the individuals listed on this form and I are eligible for the overage requested. I understand the benefit eletions made on this appliation are in effet for as long as I ontinue to meet PEBB s eligibility requirements, or until I elet to hange them subjet to the provisions of PEBB s plan. I have read the benefit materials and I understand the limitations and qualifiations of the PEBB benefits program. If neessary, I authorize premium payments deduted from my pay. I understand that: A person knowingly makes a false statement in onnetion with an appliation for any benefit may be subjet to imprisonment and fines. Knowingly making a false statement may subjet me to termination of enrollment, denial of future enrollment, or ivil damages. If I fail to report a hange that made an enrolled family member ineligible, PEBB may onsider my omission an intentional misrepresentation of a fat material to my enrollment. In that ase, PEBB may terminate the family member s overage retroatively, pursuant to PEBB rules. You must submit a midyear hange form to your benefit offie within 30 days of the date when an individual you provide overage for is no longer PEBB eligible. If your notie is late, you and your qualified benefiiaries may lose the right to elet COBRA. This form supersedes all forms and submissions I previously made for PEBB overage for individuals named. I ertify under penalty of the State of Oregon laws that the foregoing is true and aurate to the best of my knowledge and belief. I delare the dependents listed and I are eligible for the overages requested per PEBB Administrative Rule (OAR) Division 15. I understand that they are subjet to penalty for false laims. Partiipant signature Date Submit ompleted form to BenefitHelp Solutions, PO Box 40548, Portland, OR or fax to or Keep a opy of your benefit forms for your reords. Any alteration of this form may result in it being ineffetive. Page 5 of 5