Tips for Completing the PERACare Enrollment/Change Form

August 15, 2017
  • Closeup on a person writing with a pen on a clipboardDO submit a form if you are making changes, enrolling, or canceling coverage.
  • DO sign and date your form and include your name, birthdate, Social Security number, and the information for any dependents you are enrolling.
  • DO complete only the section(s) on the back of the form for coverage(s) you wish to change (health, dental, vision).
  • DO submit your form prior to November 9, 2017. All changes made during open enrollment become effective January 1, 2018.
  • DO NOT submit a form if you would like to continue with your current coverage.

Photo: Visivasnc/iStock/Thinkstock

Visit the “PERACare for Retirees–2018” section on in early October for instructional videos on completing a PERACare Enrollment/Change Form.