Peia Change In Status Form - State Of West Virginia Page 2

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Change in Status Form

Page 2

Policyholder's Last Name: _______________________________________________________ Last four digits of SSN: __________________________

COBRA

Under Federal COBRA law, PEIA must offer continued coverage to qualified policyholders or dependents under certain circumstances. If you qualify, you

will be sent notification with the necessary applications by HealthSmart Benefit Solutions, who administers COBRA for the PEIA. You will have a limited

amount of time to elect continuation of coverage. If dependent's address is different than the policyholder's address, please provide the dependent's address

here:

Dependent Name: ___________________________________________________________________________________________________________

Street Address: _____________________________________________________________________________________________________________

City, State, Zip ______________________________________________________________________________________________________________

Premium Discount Affidavits

Tobacco Affidavit: Mark which members of the family (if any) use tobacco and sign the acceptance box below. If no one enrolled on your coverage

uses tobacco, you will receive a premium discount on your health coverage and/or optional life insurance. I acknowledge by signing the Acceptance box

below that WVPEIA or its agents have access to my medical records to check my tobacco use status.

Who uses tobacco:

Policyholder

Dependent (spouse and/or children)

No Tobacco Users within the last six (6) months

Living Will Affidavit: PEIA offers a premium discount to health policyholders who have executed a Living Will/Advance Directive. If you have a valid

living will, please check the box beside the statement below and sign the form in the Acceptance box below.

By checking this box, I acknowledge that I have executed a valid Living Will or advance directive, and that I have discussed its contents with the

appropriate parties, including my family and my health care provider.

Acceptance

I hereby accept the changes to my group coverage I have indicated above. I understand that the PEIA may change the types or levels of benefits or the

amount of contribution, and that the changes I have made may affect my contributions. I certify that the above information is true and correct and

understand that providing false information on this form is illegal and that those who provide false information may be prosecuted. I hereby consent, for

myself and my covered dependents, to the release to PEIA and to the plan I have selected, of all medical and prescription drug information needed to

process claims, determine coverage, review utilization, investigate complaints, assess quality of care, evaluate plan performance or any other process

involved in my treatment, payment of claims or health care operations.

Employee's Signature:

Date:

Employer Information -- TO BE COMPLETED BY AGENCY BENEFIT COORDINATOR

Account Number

Agency Name (optional):

_______________________________________________________________________________________

Effective Date of Status Change

Index Code

I hereby certify that, to the best of my knowledge, the information contained herein is accurate. I further certify that the applicant meets the minimum

eligibility requirements for the Public Employees Insurance Plan.

Authorized Signature:

Date:

Please submit only the original to PEIA

Revised May 26, 2015