Bookmark & ShareThe PEBB Program provides the following worksheets to help employers determine an employee’s eligibility for PEBB health coverage. The method is consistent with PEBB’s rules and laws.
Your employer’s personnel, payroll, or benefits office will use one of these worksheets to determine your eligibility for PEBB health coverage if:
- You are a new employee, faculty, or appointed/elected official.
- You leave work (either temporarily or permanently).
- You return to work.
- Your employment situation changes.
Your employer will select and complete the worksheet that best matches your situation, and ask you to review and sign it.
If you have any questions about your eligibility for PEBB health coverage, ask your employer’s personnel, payroll, or benefits office.
New Hires Worksheets
A-1 Employees (salaried and hourly)
A-2 Employees (seasonal – 3 to 11 months this season, work that recurs)
A-3 Faculty (first faculty work at your institution)
A-4 Legislators, Judges, or Newly Appointed Officials
Existing Employees/Faculty Review of Benefit Eligibility Worksheets
B-1 Salary, Hourly, Seasonal (retrospective review or increase in anticipated work pattern)
B-2 Faculty (second quarter/semester or increase in anticipated work pattern)
B-2a Faculty Maintaining employer contribution using quarter-to-quarter/semester-to-semester review
B-3 Faculty Requesting 2-Year Averaging
B-3a Faculty Maintaining employer contribution using 2-year averaging
B-4 Hourly/Salaried Employees Changing Positions
B-5 Seasonal Employees Changing Positions or Returning to Work during their Off-Season
B-6 Hourly/Salaried Employees with a Change in Employment Status due to Layoff
B-7 Seasonal Employees with a Change in Employment Status due to Layoff
Eligible Employees Leaving Work – Temporarily or Permanently Worksheets
C-1 Approved Leave (includes approved leave without pay, educational leave, time-loss/workers compensation, and appealing dismissal)
C-2 Approved FMLA
C-3 Faculty - Summer or Off-Quarter/Semester
C-4 Seasonal Employees - Off-Season
C-5 Active Military Duty for Less than 31 Days (Coming 2012)
C-6 Active Military Duty for 31 Days or More (Coming 2012)
C-7 Layoff
C-8 Terminating or Separating from State Service or Loss of Eligibility
C-9 Retiring
C-10 Employee Applying for Disability Retirement
Employees Returning to Work Worksheets
D-1 From Time-loss/Workers Compensation, Military Duty, Ed Leave, Leave Without Pay
D-2 From Layoff
D-3 Faculty after Quarter/Semester Gap in Employer Contribution
D-4 Following Overturning of Dismissal (Coming 2012)
D-5 Seasonal Employees Returning from their off Season with no Employer Contribution for Benefits
Dependents
E-1 Dependent Eligibility
E-2 Dependents with Disabilities and Extended Dependents
