Pebb Form 107 026 PDF Details

The need for accurate and comprehensive paperwork is essential when it comes to meeting the legal requirements of any business or organization. To ensure compliance with applicable laws, organizations must keep detailed records in accordance with their specific industry regulations. One such form is the Pebb Form 107 026 – a document that outlines an employer’s obligation to report insurance benefits for their employees. This post will provide an overview of this form and discuss why it’s important for employers to properly fill out this document.

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

Form Preview Example

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

You could work with Pebb Form 107 026 effortlessly by using our PDFinity® online tool. To have our tool on the forefront of efficiency, we aim to put into action user-driven features and enhancements on a regular basis. We're routinely happy to get suggestions - assist us with reshaping PDF editing. Here's what you'd have to do to get started:

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.

Step 3: Spell-check the information you have entered into the form fields and click on the "Done" button. Make a 7-day free trial account at FormsPal and obtain immediate access to Pebb Form 107 026 - with all transformations saved and available in your personal account page. We don't share or sell any details you use whenever completing documents at our website.

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