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Public Employees' Benefit Board

Forms  
2012 Enrollment
Employee Enrollment Corrections
Flexible Spending Account Corrections
Employee Core and Optional Benefits
Employee Flexible Spending Accounts
Retiree Health Plans
Retiree Enrollment Corrections
Self-Pay Health Plans
Self-Pay Enrollment Corrections
COBRA Enrollment Corrections
Long Term Care Plan
Covering Others
Affidavit of Dependency
Affidavit of Domestic Partners
Grandchild by Affidavit
Domestic Partner for Tax Status
Domestic Partnership Termination
Midyear Change
Midyear Change
Midyear Tobacco-use Change
Flexible Spending Account
Healthcare FSA Prepay Request
Qualified Reservist Distribution Request
Life & Disability Insurance
Transfer Premium Payment
Disability Insurance Claims Packet (pdf)
Life Insurance Claims Packet (pdf)
Medical History Statement (pdf)
Medical History Statement Online
Optional Life Insurance Portabilty (pdf)
Retiree Life Conversion Packet (pdf)
Retiree Life Insurance Application (pdf)
Retiree Life Insurance Termination
MEDEX Travel Assist Program
Long Term Care Insurance
UNUM long term care insurance coverage
Long Term Care Continuation Form
Transfer Premium Payment
Other Forms
Appeal
Beneficiary Designation
CDL Exam Eligibility Voucher
Flexible Spending Account Claims
VSP Reimbursement
Weight Watchers Participation Form
Can't find it?
View DAS' master forms page

Page updated: December 28, 2011