Type of change(s) requested:
Social Security #:
Name:
First
MI
Last
Email
Previous name
Previous address:
Signature
Date
Benefits Identification #:
Membership type:
(check all that apply):
Section I PERSONAL INFORMATION
Section III ADDRESS CHANGE
County Code
State
Zip Code
Street
City
Apt.
Work phone
Primary phone
New address:
USE THIS ADDRESS FOR:
Alternate address: Enter only if you would like to use two different addresses for insurance and retirement.
Reason for change:
Section IV SIGNATURE
Insurance:
Retirement:
PEBA Insurance
Benefits Group No.:
Section II NAME CHANGE
(Please refer to the instructions to determine what documentation is required.)
Address changes can also be entered online through MyBenefits and Member Access at www.peba.sc.gov.
Group name:
Effective date of change:
Name/Address Change Form
S.C. Public Employee Benefit Authority
202 Arbor Lake Drive
Columbia, SC 29223
Form 1239
Page 1
Revised 5/14/2018
Print or type in black ink.
Please read the instructions on Page 2 before completing this form.
Suffix
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