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Click ‘Get Form’ to open it in the editor.
Begin by filling out the entity's name and contact information in the designated fields. Ensure accuracy as this information is crucial for communication with PEBA.
Next, indicate your desired effective date for insurance coverage. This should be at least six months from the submission date.
Complete the eligibility determination section by providing details about your employees, including any Medicare-eligible individuals and dependents.
Review all entered information carefully before submitting. Use our platform’s features to highlight or annotate any important notes for clarity.
Once satisfied, click ‘Submit’ to send your completed form directly to PEBA for processing.
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If it is determined you are eligible to participate in the program, PEBA will contact you and provide details about your next steps, including coverageRead more
Employees may not make changes to their benefits other than those specified in the NMSN, which PEBA will determine. Employees are not allowed to make.Read more
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