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Public Employees' Benefit Board

Forms  
Remedy for Loss of Coverage
Remedy Form
2010 Employee Enrollment
Employee Enrollment (core and optionals)
Flexible Spending Account Enrollment
2010 Self-pay Enrollment
Retiree Enrollment
Self-pay Enrollment
Self-pay Dependent Certification
2009 Enrollment
Employee Medical and Dental Plans
Retiree Medical and Dental Plans
Self-pay Medical and Dental Plans
COBRA Medical and Dental Plans
Life and Disability Insurance
Flexible Spending Account
Covering Others
Dependent Certification for Self-pays
Affidavit of Dependency
Affidavit of Domestic Partners
Domestic Partner for Tax Status
Domestic Partnership Termination
Midyear Change
2009 Life and Disability Insurance
2009 Medical & Dental Plans
2009 Flexible Spending Account
Healthcare FSA Prepay Request
Life & Disability Insurance
Disability Insurance Claims Packet (pdf)
Life Insurance Claims Packet (pdf)
Medical History Statement (pdf)
Medical History Statement Online
Optional Life Insurance Portabilty (pdf)
Retiree Life Conversion Packet (pdf)
Retiree Life Insurance Application (pdf)
Retiree Life Insurance Termination (pdf)
MEDEX Travel Assist Program
Long Term Care Insurance
UNUM long term care insurance coverage
Other Forms
Beneficiary Designation
Transfer Premium Payment
Appeal
Qualified Reservist Distribution Request
2009 CDL Exam Eligibility Voucher
2010 CDL Exam Eligibility Voucher
Flexible Spending Account Claims
VSP Reimbursement
Can't find it?
View DAS' master forms page
 
Page updated: November 16, 2009

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