Pennsylvania Employee Benefit Verification Form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Commonwealth employee’s name in the designated field. This is crucial for identifying the primary member of the PEBTF health benefits.
3. Next, input the Commonwealth employee number and date of birth (mm/dd/yyyy) to ensure accurate record-keeping.
4. Fill in your spouse’s name and date of birth in the respective fields. This information is necessary for verifying eligibility.
5. Indicate your spouse's employment status by selecting either Full-Time or Part-Time, and confirm if they are employed or retired.
6. Complete the section for employer verification by providing the employer's name and answering questions regarding health insurance eligibility.
7. Finally, ensure all information is accurate, sign, and date the form before submission. Remember, this form must be submitted within 30 days of signing.

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