Pebtf 2 employee enrollment change form online - pebtf 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the 'Transaction' section. Select the appropriate option such as 'Enrollment', 'Add Dependent(s)', or 'Cancel Coverage'. Ensure you check the box that corresponds to your request.
3. In the 'Employee Data' section, fill in your personal information including your name, social security number, and contact details. Make sure all fields are completed accurately.
4. Choose your medical plan option by selecting either HMO or PPO. If you select HMO, indicate your Primary Care Physician (PCP) and their ID number.
5. Complete the 'Dependent Data' section for any dependents you wish to add or remove. Provide their names, dates of birth, and social security numbers as required.
6. In the 'Remarks' section, provide any additional information or reasons for changes if necessary.
7. Finally, sign and date the form at the bottom to authorize your application for enrollment or change.

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