Pebtf forms 36 2025

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The document is an Employer Benefit Verification Form for the Pennsylvania Employees Benefit Trust Fund (PEBTF), which outlines the health benefits eligibility requirements for spouses or domestic partners of Commonwealth employees. It specifies that spouses/domestic partners must enroll in their own employer's health coverage to qualify for PEBTF secondary benefits. The form requires information from both the PEBTF employee and an authorized representative of the spouse's/domestic partner's employer regarding employment status and health insurance availability.

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What is spouse attestation?

To enroll your spouse in the SAG-AFTRA Health Plan, you need to complete a spouse coverage attestation when you qualify for your next annual benefit period. This is required it establishes your spouses eligibility for benefits.

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