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Category: Life and Accident Policy Forms

Life Insurance Enrollment and Change Forms

All benefits eligible employees must complete these forms to designate beneficiaries for the basic coverage funded by the state.  You may also apply for additional coverage using the enrollment form.  Online enrollment and beneficiary designation can also be completed online using your myPEHP online account. Life Insurance Enrollment Form Disclosure Form Group Term Life Change Form

Life Insurance Enrollment Form for Spouse/Dependents

To enroll your spouse and/or dependents in the Life Insurance Plan PEHP offers complete this form and submit to PEHP directly.  This enrollment may also be completed using the online PEHP enrollment option available on myPEHP. Life Insurance Spouse Dependent Enrollment Form

Life Insurance Enrollment and Change Forms for EXEMPT Employees

If you are CAREER SERVICE EXEMPT, you may be eligible to enroll in Exempt Life Insurance (state-paid). See below for the applicable enrollment, disclosure and change forms. Information about life insurance for CAREER SERVICE employees, can be found here. For questions, please contact the Employee Resource Information Center (ERIC) at 801-538-3742. State-Exempt Group Term Life Enrollment Form Disclosure Form Group Term Life Change Form

Accidental Death & Dismemberment Form

Complete this form to enroll in or make changes to the Accidental Death & Dismemberment optional plan offered by PEHP. Accidental Death & Dismemberment Enrollment/Change Form

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