PEBTF Dependent Attestation Form (PEBTF-16)

PEBTF DEPENDENT ATTESTATION FORM
(for Dependents Age 19 to 26)
Note: All information requested below MUST be completed.
Active
Retiree
Retired State Police
EMPLOYEE/RETIREE INFORMATION (Please print or type):
1. Last 4 digits of your Social Security number:
2. Name (First, M., Last):
3. Address: Street
City
4. Date of birth:
State
ZIP Code
The dependent must continue to be enrolled in the same plan in which the subscriber is enrolled.
To enroll a dependent who is age 19 to 26, please submit this form with any other required forms to the
HR Service Center or to your local HR Office (if your agency is not served by the HR Service Center) or to
SERS if you are a retiree.
DEPENDENT INFORMATION (Please print or type):
5. Last 4 digits of dependent's Social Security number:
6. Dependent's name (First, M., Last):
7. Is Dependent's address the same as the subscriber?
Yes
(If address is not the same as the subscriber, please list address below)
8. Address: Street
City
State
9. Telephone number: Home: ( )
Work: (
)
10. Dependent's date of birth:
Please answer the following questions:
Is the dependent eligible for other employer-sponsored health
coverage (other than through a parent)?
Does the dependent have other employer-sponsored health coverage
(other than through a parent)?
No
Zip Code
Yes
No
Yes
No
If yes, what is the effective date of coverage?
Provide name and address of dependent's employer
SUBSCRIBER: I CERTIFY THAT THIS INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. BY
SIGNING THIS CERTIFICATION, I AM AUTHORIZING THE PEBTF TO CONTINUE COVERAGE FOR MY
DEPENDENT.
Member's Signature:
Date Signed:
NOTE: Eligibility for benefit coverage for dependents to age 26 and continuation of this coverage is subject to periodic
evaluation and recertification. Should dependent or any other information on this Attestation Form change at any time, benefit
coverage may be reconsidered by the PEBTF.
PEBTF-16 (HR/SERS; initial enrollment)
Rev 11-2010