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Category: Life and Accident Policy Forms

PEHP Disclosure Authorization

Complete this form to authorize disclosure of medical information to Group Time Life Program. HIPAA Disclosure Authorization Form

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

Complete these forms to enroll in Life Insurance if you are in an appointed, elected or other eligible positions designated by your agency.  This is not the enrollment form for career service employees or employees who are eligible for benefits during a temporary assignment.  If you have questions, please contact a Human Resource Representative at ERIC by calling 801.538.3742 or your local HR office. 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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