Public Employees' Benefit Board - Member, Admin., Vendor Forms

Member, Admin and Vendor Forms

• If you completed Open Enrollment between October 1, and October 31, 2025.
• Changes or corrections are allowed until February 28, 2026. Please use Open Enrollment Correction form.
• If you didn't complete Open Enrollment between October 1, and October 31, 2025.
• Surcharge corrections only are allowed, but no core (medical, dental, vision) or Optional Benefits. Please use the Open Enrollment Correction form.

If you'd rather print or fill in and share your form:

1. Open a form by clicking the link under Document Title.
2. Save it to your computer before entering information or it might be lost when you do save it.
3. Please complete all fields.
4. Save your completed form before sending or sharing it.
5. The bottom of each form will let you know where to send it.

For questions: visit our Contact Information page.