Pebb Form 107 026 PDF Details

Endings can be just as significant as beginnings, especially when it comes to the dissolution of a domestic partnership. For employees and their domestic partners registered under the Public Employees' Benefit Board (PEBB) Affidavit of Domestic Partnership in Oregon, the formal process of terminating this legal relationship is facilitated through the PEBB 107 026 form. This critical document is a requisite for those seeking to officially end their domestic partnership, necessitating a meticulous completion of several sections aimed at capturing comprehensive details about both the employee and the domestic partner. From providing personal and contact information to declaring the termination date of the partnership, the form serves as a pivotal step toward the discontinuation of shared benefits. It emphasizes the necessity of filing within specific timeframes to ensure the proper execution of benefits termination, offers guidance on how to proceed with potential insurance coverage for the former partner, and underscores the importance of submitting this form in conjunction with relevant update forms to the appropriate human resources or benefits office. Moreover, it outlines the procedures for those needing to continue their insurance through COBRA. Thus, navigating the termination of a domestic partnership through the PEBB 107 026 form is a structured process that underscores the legal and administrative steps required to decisively end benefit entitlements that were once extended to domestic partners.

QuestionAnswer
Form NamePebb Form 107 026
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesDPterm get hard copy of pebb mid year change forms

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PEBB Termination of Domestic Partnership

Instructions

www.oregon.gov/DAS/PEBB

Complete this form to term a domestic partnership established under a PEBB Affidavit of Domestic Partnership. Submit this form along with the appropriate update form to your agency/university payroll or benefit office.

•The effective date for termination of coverage due to lose of eligibility is the last day of the month the event occurred.

SECTION A

•Complete each item in this section

SECTION B

•Complete each item in this section for domestic partner.

SECTION C

•Read and complete each item in this section.

SECTION D

•Read sign and date the form.

•Make a copy for your records and submit. Sending your forms to the wrong address will delay your change.

Active and Semi Independent Agency Employees:

Within 60 days of QSC to: Agency/University Payroll,

Personnel or Benefit Office

Beyond 60 days of QSC to: PEBB

1225 Ferry St. SE

Salem, OR 97301

Salem (503)-373-1102

Toll-free (800)-788-0520

COBRA and other Self-Pay Participants Only to:

BenefitHelp Solutions (BHS)

PO Box 67240

Portland, OR 97268-1240

Portland (503)-765-3581

Toll-free (800)-556-3137

1

107-026(02/05/08)

Termination of Domestic Partnership

SECTION A – EMPLOYEE INFORMATION

LAST NAME

FIRST NAME

 

 

DATE OF BIRTH (MM-DD-YYY)

 

 

MI

ID NUMBER (SSN, OURS#, Benefit#)

 

 

 

 

GENDER

฀ FEMALE

฀ MALE

RESIDENCE ADDRESS

CITY

STATE ZIP

COUNTY

HOME PHONE

MAILING ADDRESS

AGENCY

WORK PHONE

E-MAIL ADDRESS

SECTION B – DOMESTIC PARTNER INFORMATION

LAST NAME

FIRST NAME

MI

ID NUMBER (SSN, OUS#, Benefit#)

 

 

 

 

CURRENT ADDRESS (if known)

DATE OF BIRTH (MM-DD-YYY)

SECTION C – EMPLOYEE DECLARATION AND DATE OF TERMINATION

I ____________________________________________ (please print) file this PEBB Termination of Domestic Partnership form

to revoke the PEBB Affidavit of Partnership previously filed by me.

This relationship ended on (MM-DD-YYYY)__________________.

I understand that:

I must cancel all PEBB-sponsored insurance coverage for my former domestic partner and/or domestic partner’s child(ren).

Attach the appropriate PEBB Medical and Dental and/or Life and Disability Update Form canceling coverage for ineligible individuals.

My former domestic partner, who filed the Affidavit of Domestic Partnership with me, may have the option to continue benefit coverage through COBRA regulation and self-payment of premiums.

Employee Signature:______________________________________________ Date:_______________________________

“PEBB Use Only”

Approved by PEBB(initials):________________ Date:________ Effective Date: ____________ PDB Updated by (initials):__________

2

107-026(02/05/08)

How to Edit Pebb Form 107 026 Online for Free

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Step 1: Click on the "Get Form" button at the top of this page to open our PDF tool.

Step 2: When you open the tool, you will notice the form prepared to be filled out. Aside from filling out different blanks, it's also possible to perform several other things with the PDF, including writing any text, modifying the original textual content, adding graphics, putting your signature on the form, and more.

In order to finalize this document, make sure you provide the information you need in each area:

1. It is recommended to fill out the Pebb Form 107 026 correctly, thus be careful while working with the segments containing these specific blanks:

Find out how to prepare Pebb Form 107 026 stage 1

2. After performing the last step, go to the subsequent part and enter the essential particulars in all these blanks - to revoke the PEBB Affidavit of, This relationship ended on MMDDYYYY, I understand that, cid, I must cancel all PEBBsponsored, cid Attach the appropriate PEBB, individuals, cid My former domestic partner who, benefit coverage through COBRA, Employee Signature Date, Approved by PEBBinitials Date, and PEBB Use Only.

Completing part 2 of Pebb Form 107 026

You can certainly make errors while filling out the cid, hence make sure to go through it again prior to deciding to finalize the form.

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