Peia Form PDF Details

Are you looking to understand how to fill out the 2021 Peia form? Whether you need information about personal liability protection or general requirements, we have it all here. We'll walk through everything from eligibility criteria and frequently asked questions, to helping with online applications and understanding what documentation may be required along the way. Get ready - you're one step closer to completing your Peia form!

QuestionAnswer
Form NamePeia Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesppb plan form, peia form online, peia form, blank sudoku form print

Form Preview Example

PEIA PPB Plan

Coordination Of Benefits Form

In order to keep our records current, it is a PEIA requirement that this questionnaire be completed every 12 months. Please return this questionnaire within 30 days to prevent delays in future claim submissions.

Policyholder Name___________________________________________________

ID Number_________________________________________________________

Address____________________________________________________________

Dependents Covered__________________________________________________

1.Spouse’s Name _______________________________ Date of Birth _________________

2.Do you or any of your dependents have other insurance?

Yes No if yes: Single Family

Type of Coverage

Medical Rx Drug Dental Vision Hospital

3.Employee’s Name ____________________________________________________________

4.Please provide the name, address, and effective date of the other insurance

______________________________________________________________________________

if Medicare, please advise and give effective date _____________________________________

5.Does the other insurance plan use the gender rule or the birthday rule for coordination of benefits? Gender Birthday

6.If the other insurance has terminated, pleasE provide the termination date:_________________

Employee Signature ____________________________________ Date____________________

Day Phone _________________________

Please return this completed letter within 30 days for prompt handling. If related claims are received requiring this same information, you will not receive additional requestS.

Mail To:

HealthSmart

P O BOX 3262

CHARLESTON, WV 25332-3262

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This form needs specific information; in order to ensure accuracy, be sure to bear in mind the recommendations further down:

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A way to fill in wv peia benefits form portion 1

2. After filling out the last part, go to the next stage and fill in all required particulars in these blank fields - Spouses Name Date of Birth Do.

A way to prepare wv peia benefits form step 2

Be really careful while completing Spouses Name Date of Birth Do and Spouses Name Date of Birth Do, since this is the section in which many people make mistakes.

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