• Type or print clearly in black ink. Inaccurate, incomplete, or illegible information may delay coverage.
• List eligible family members you wish to cover or remove from coverage. This form replaces all Employee Enrollment/
Change forms previously submitted.
2015 Employee Enrollment/Change
Additional changes you can make during the PEBB Program’s annual open enrollment
All changes become effective January 1 of the following year.
Check the box(es) next to the change requested.
Add dependent(s) Change dental plan
Remove dependent(s) Enroll after waiving medical coverage
Change medical plan Waive medical coverage due to enrollment in other employer-based group medical insurance
HCA 50-400 (10/14)
Are you making changes to an existing account?
Yes If yes, what changes? (Check all that apply in the sections below.)
No (If no, go to Section 1.)
Changes you can make anytime Give date of event/change _____________________________
Name change Address change Submit a change to a premium surcharge attestation
Remove dependent(s) from coverage due to loss of eligibility (divorce, dissolution of registered domestic partnership, death, or
other loss of eligibility for PEBB benets). Your benets ofce must receive this form no later than 60 days after the event.
If applicable, provide former dependent’s new address:
Additional changes you can make if an event creates a special open enrollment
The PEBB Program only allows changes outside of an annual open enrollment when an event creates a special open
enrollment. The change must be allowable under Internal Revenue Code and correspond to and be consistent with a special
open enrollment event for the subscriber, the subscriber’s dependent, or both. You are required to provide proof of the event
that created the special open enrollment. Your benets ofce must receive this form and proof of the event no later than
60 days after the event. However, if adding a newborn or newly adopted child increases your premium, you must submit this
form no later than 12 months after the birth or adoption.
Check the box next to each change you are requesting and indicate the corresponding event(s) on the following page.
In most cases, the enrollment or change will be effective the rst day of the month after the event date or the date the form is
received, whichever is later.
Add dependent(s) (allowable under events 1, 2, 3, 4, 5, 6, 7, 9, 10, 11)
Enroll after waiving medical coverage (allowable under events 1, 2, 3, 4, 5, 6, 7, 9, 10, 11)
Change medical plan (allowable under events 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14)
Change dental plan (allowable under events 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14)
Remove dependent(s) (allowable under events 1, 5, 6, 9, 10)
Waive medical coverage due to enrollment in other employer-based group medical insurance
(allowable under events 1, 5, 6, 9, 10)
Give date of event _____________________________
(this section continued on next page)
Agency name Agency/subagency Insurance effective date Hire date
Subscriber’s last name First name Middle initial Social Security number