CSS2HTML: WEB1239.XDP

Type of change(s) requested: 

Social Security #:

Name:

First

MI

Last

Email

Previous name

First

MI

Last

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

County Code

State

Zip Code

Street

City

Apt.

New address:

County Code

State

Zip Code

Street

City

Apt.

USE THIS ADDRESS FOR:

Alternate address: Enter only if you would like to use two different address 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 6/28/2017

Print or type in black ink.

Please read the instructions on Page 2 before completing this form.

USE THIS ADDRESS FOR:

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