Change Request Benefit Form

I hereby request coverage and authorize that any requested contribution for the coverage to which I may be entitled be deducted from my earnings. I am eligible for coverage and am working at least the number of hours per week required by my Employer.

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Complete this form and any applicable state-required replacement forms. Please contact the current carrier for any requirements it may have for transferring money to another company. If you are completing this form for a 403 b or 403 b 7 accountcontract please contact your employer for any processing instructions the employer or third party administrator may require.

Change Coverage To change coverage, mark box provided with the old coverage quotFromquot and the new coverage quotToquot. If changing to a coverage that includes dependents, enter dependent information in the boxes at the bottom of the form For medical coverage, the social security numbers are required.

Please upload your documents to support the change, such as your marriage certificate, divorce decree, birth certificate, or loss of coverage letter. COBRA for Network Companies Please update the Benefit Update File with all your termination information and upload it here.

F-50 This form is used to request a name or address change with OPERS. A recipient receiving a benefit or payment may also use this form to request a change to their banking information. Change requests cannot be processed without required supporting documentation and a signature in Step 5.

Change Request This form can be used to request multiple changes to your policy. Use this form to change or correct the name or address of the owner, beneficiary, payer, insured, or payee change the premium billing frequency and add or revoke the Automatic Premium Loan APL or Automatic Application of Dividend provision.

Benefit Change Request form Once you click Update Benefit Coverage, you will need to complete the following fields on the request form Qualifying life event This required field categorizes all QLE types into six sections, in which you can find your qualifying life event type Most Common Changes in Household Changes in Dependent Health Coverage

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Not all forms are listed. If you can't find the form you need, or you need help completing a form, please call us at 1-800-772-1213 TTY 1-800-325-0778 or contact your local Social Security office and we will help you.