PEBB - New Employee Enrollment - Medical and Dental

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Select the description that fits you:

I am an employee of a state agency, higher-education institution or community/technical college that offers PEBB medical and dental benefits.
I am an employee of a K-12 district or employer group that offers PEBB medical and dental benefits.
I am an employee of a group that offers PEBB medical benefits only.

2012 Enrollment

The PEBB Program offers the following benefits:

Medical and Dental
Life & Accidental Death & Dismemberment (AD&D) Insurance
Long-term Disability Insurance
Flexible Spending Account (optional)
Dependent Care Assistance Program (optional)
Long-term Care Insurance (optional)
Auto and Home Insurance (optional)

How Can I Learn More About The Benefits and Enrollment Process?

Read the 2012 Employee Enrollment Guide for enrollment, eligibility, and benefits information; it includes enrollment forms for PEBB medical and dental, life insurance, and long-term disability insurance.

When Are My Enrollment Forms Due?

For	Fill out and submit print out to your employer	No later than
Medical and Dental	Employee Enrollment/Change form (435 KB) Also complete a dependent certification form to enroll your: Domestic partner (240.4 KB) (or partner's children) Dependent with disabilities (297 KB) Extended dependent (290.2 KB) If enrolling family members, you must also provide documents that prove their eligibility within PEBB's timelines, or PEBB will not enroll them.	31 days after the date you become eligible (this is generally the first day of employment)
Life Insurance	Life Insurance Enrollment Form (100.8 KB) (for basic and supplemental life insurance that doesn't require prior approval) Life Insurance Evidence of Insurability Form (97.7 KB) (for supplemental life insurance amounts that require prior approval)	60 days after the date you become eligible
Long-term Disability (LTD) Insurance	Long Term Disability (LTD) Enrollment/Change Form (62.1 KB) (for basic and optional LTD Coverage that doesn't require prior approval) Long Term Disability (LTD) Evidence of Insurability Form (213.7 KB) (for optional LTD insurance amounts that require prior approval)	31 days after the date you become eligible
Flexible Spending Account (FSA) Dependent Care Assistance Program (DCAP) FSA and DCAP are available only to benefits-eligible employees at state agencies and higher-education institutions	FSA & DCAP Enrollment Form (same form for one or both programs)	31 days after the date you become eligible
Long-term Care Insurance	For enrollment form, call John Hancock Insurance at 1-800-399-7271	31 days after the date you become eligible