Midyear Change Life Event Approved by: Approved date: Offie use only Effetive date: See the Summary Plan Desription for more information on benefits at www.oregon.gov/oha/pebb. Contat information (You must omplete all fields) PEBB benefit number (P########), OR#, University ID or Lottery ID Last name First name Middle Ageny M F Contat address Chek if new address Apartment # City State ZIP Residene ZIP ode Work ZIP ode Work email Personal email (optional) Date of birth () Work phone Home phone (optional) Are you Mediare eligible No Yes 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) for the purpose of reeiving benefit information? No Yes Ethniity: Hispani Non-Hispani/Non-Latino Unknown Refuse Rae:: Asian White Unknown Refuse Other Blak/Afrian Amerian Amerian Indian Alaska Native Native Hawaiian/Other Paifi Islander Family overage (List all eligible family members you want to provide PEBB overage. Attah additional dependent sheet if neessary.) Spouse/Domesti Partner Last name First name Middle Relationship Spouse Partner Address (Complete only if new): Is this dependent Mediare eligible? No Yes Ethniity: Hispani Non-Hispani/Non-Latino Unknown Refuse Rae: Asian White Unknown Refuse Other Blak/Afrian Amerian Amerian Indian Alaska Native Native Hawaiian/Other Paifi Islander Page 1 of 8 MSC 5558 (09/2018)
If you listed a Domesti Partner, mark the type of Domesti Partnership Registered Certifiate of Domesti Partnership (Copy not required) You have a registered ertifiate issued by an Oregon ounty lerk to you and your same sex partner. 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. Affidavits need to be submitted along with this form. Note: Payroll/Benefit offies will not proess the enrollment for the individual until all the doumentation has been submitted. Eligible dependent hildren (List the eligible hildren you want to provide PEBB overage. Attah a separate sheet if neessary. Required affidavits and appropriate legal douments for hild by affidavit or grandhild need to be submitted along with this enrollment form. Note: Payroll/Benefit offies will not proess the enrollment for the individual until all the doumentation has been submitted.) Child Last name First name Middle Dependent Status Child Partner s hild Grandhild by affidavit(both parent & grandhild are required to be living with you) 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) Address (Complete only if new): Is this dependent Mediare eligible? No Yes Ethniity: Hispani Non-Hispani/Non-Latino Unknown Refuse Rae: Asian White Unknown Refuse Other Blak/Afrian Amerian Amerian Indian Alaska Native Native Hawaiian/Other Paifi Islander Child Last name First name Middle Dependent Child Partner s hild Grandhild by affidavit(both parent & grandhild are required to be living with you) Status 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) Address: Complete only if different Is this dependent Mediare eligible? No Yes This will not affet enrollment. Ethniity: Hispani Non-Hispani/Non-Latino Unknown Refuse Rae: Asian White Unknown Refuse Other Blak/Afrian Amerian Amerian Indian Alaska Native Native Hawaiian/Other Paifi Islander Page 2 of 8 MSC 5558 (09/2018)
Child Last name First name Middle Dependent Child Partner s hild Grandhild by affidavit(both parent & grandhild are required to be living with you) Status 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) Address: Complete only if different Is this dependent Mediare eligible? No Yes Ethniity: Hispani Non-Hispani/Non-Latino Unknown Refuse Rae: Asian White Unknown Refuse Other Blak/Afrian Amerian Amerian Indian Alaska Native Native Hawaiian/Other Paifi Islander Child Last name First name Middle Dependent Child Partner s hild Grandhild by affidavit(both parent & grandhild are required to be living with you) Status 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) Address: Complete only if different Is this dependent Mediare eligible? No Yes Ethniity: Hispani Non-Hispani/Non-Latino Unknown Refuse Rae: Asian White Unknown Refuse Other Blak/Afrian Amerian Amerian Indian Alaska Native Native Hawaiian/Other Paifi Islander Page 3 of 8 MSC 5558 (09/2018)
What hanged in your life? (The event date must be inluded.) See QSC Matrix at http://www.oregon.gov/oha/pebb in the summary Plan Desription Meet eligibility for domesti partnership Birth Adoption or plaement for adoption (legal doumentation required) Dependent gains other medial group overage National Medial Support Notie (NMSN) Employment status hange (desribe) Divore or annulment Termination of domesti partnership Death of dependent or spouse Dependent loses other medial group overage Employee gains other group overage Move out of urrent plan s servies area Loss of other group medial overage Tobao midyear hange info (Self): Quit Never used Medial provider advised not to quit (medial ondtion) Used tobao in previous 12 months Have not used tobao produts in the previous 12 months Tobao midyear hange info (Spouse/Domesti Partner): Quit Never used Medial provider advised not to quit (medial ondtion) Used tobao in previous 12 months Have not used tobao produts in the previous 12 months Page 4 of 8 MSC 5558 (09/2018)
Did you terminate overage for an individual? Name and address for all dependents is required for COBRA notie. Name Address City and State ZIP Deline all PEBB benefits If you deline ore benefits (medial/dental/vision/employee basi life), you re hoosing to not partiipate in any of the PEBB programs. You will not reeive ash in lieu of the medial overage and you are not eligible to enroll in any PEBB plans. 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 Opt Out To enroll in Opt out you must attest at enrollment and eah plan year thereafter to having an alternative minimum essential medial overage. You do not need to provide proof of alternative medial overage. See information at: http://www.oregon.gov/oha/pebb/benefits/opt-out.pdf Opting Out of a medial enrollment is onditioned upon my understanding and attesting that the following statements are true: I and all other individuals for whom I reasonably expet to laim a personal tax exemption dedution for have, or will have, an alternative medial overage onsidered to be minimum essential overage through an employer sponsored medial plan for the urrent taxable year. The following overages are not eligible to Opt Out against: Oregon Health Plan/ Mediaid, Veteran s Benefit Administration Programs, Student Health, and individual market overage. I understand my employer will not pay the monthly opt-out payment to me if my employer knows or has reason to know that myself or any other member of my expeted tax family does not have or will not have the alternative overage. I understand that I must renew this attestation eah plan year and appliable tax year for whih I want the Opt Out to apply. me in Opt Out. By heking this box and signing the form I verify the above statements are true Medial Full time Part time Dental Full time Part time Kaiser Dedutible (Kaiser vision inluded with full time plan) Kaiser Permanente Kaiser HMO (Kaiser vision inluded with full time plan) Delta Dental (MODA) Premier Moda Summit Delta Dental (MODA) PPO N/A Moda Synergy Willamette Dental N/A PEBB Statewide PPO Providene Choie I Deline all Dental Plan ment Page 5 of 8 MSC 5558 (09/2018)
Vision plan VSP Basi Plan VSP Plus Inludes the Basi Plan and PLUS additional benefits I Deline all VSP ment Optional life insuranes (Complete only the setions required for enrollment.) Employee optional life insurane (Medial History Statement is required for a new enrollment for over the guarantee issue.) ($20,000 inrements, with a maximum of $600,000) or inrease overage Newly eligible ONLY (Guarantee issue) $20,000 $40,000 $60,000 $80,000 $100,000 + Canel overage Additional amount requested (Medial history required) $ = Redue overage to: Total amount $ Required: Tobao use status, hek one I have used tobao produts in the previous 12 months. (Tobao premium rates apply) I have not used tobao produts in the previous 12 months. (Non-Tobao premium rates apply.) Spouse or Domesti Partner optional life insurane (Medial history statement required for requests over the guarantee issue.) ($20,000 inrements up to maximum of $400,000) or inrease overage Newly eligible ONLY (Guarantee issue) $20,000 + Canel overage Additional amount requested (Medial history required) $ = Redue overage to: Total amount $ Required: Tobao use status, hek one I have used tobao produts in the previous 12 months. (Tobao premium rates apply) I have not used tobao produts in the previous 12 months. (Non-Tobao premium rates apply.) Dependent life insurane (provides $5,000 of overage for eah of your PEBB eligible dependent (inluding spouse or domesti partner). overage Canel overage Aidental death dismemberment (AD&D) (available in $50,000 inrements up to $500,000 for employee only or employee & dependents) for overage Canel overage Change overage Employee only overage Total overage amount $ Employee & Dependent Coverage Total overage amount $ Page 6 of 8 MSC 5558 (09/2018)
Disability insurane (The benefits will replae a portion of salary when the employee has a qualified disability laim.) Short term disability for overage Canel my overage Long term disability for overage 90 days 60% 90 days 66 2/3% 180 days 60% 180 days 66 2/3% Change my overage (selet one) 90 days 60% 90 days 66 2/3% 180 days 60% 180 days 66 2/3% Tobao use (If you enroll in a Medial plan and do not omplete this Setion a tobao surharge of $25.00 for employee and $25.00 for spouse/partner enrolled in medial will be deduted eah month) 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) I or my spouse or domesti partner quit using tobao. I or my spouse or domesti partner never used tobao Other spousal/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 deduted eah month) 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) Page 7 of 8 MSC 5558 (09/2018)
Benefiiary designation (Total of primary and ontingent perentages must = 100%. You an hange your benefiiary designation yourself anytime during the year at https://pebbbenefits.oha.oregon.gov/bms_ web/!pb.main. Note: A hange in benefiiary will revoke any previous seletions.) Standard order of survivorship (No benefiiary listed) Designate the following as benefiiary (List benefiiary) Name Relationship Address Entity Primary Contingent Individual Trust Will Individual Trust Will Individual Trust Will Individual Trust Will Whole % Employee signature and authorization (If you eleted the Medial Opt Out, your signature indiates you agree to the terms of the Opt Out alternative overage self-attestation.) 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. If you DO NOT want premiums deduted on a pre-tax basis, initial here. 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, and I understand that they are subjet to penalty for false laims. Employee signature Date Submit ompleted form to your ageny payroll or university benefits offie. Keep a opy of your benefit forms for your reords. Any alteration of this form may result in it being ineffetive. Page 8 of 8 MSC 5558 (09/2018)