(check all that apply)
Contact information - complete sections 1 and 3
Legal
spouse/dependent information (add or update) - complete sections 1, 2, and 3
Name - complete sections 1 and 3
FIRST NAME M.I. LAST NAME GENDER DATE OF BIRTH SOCIAL SECURITY NUMBER
LEGAL SPOUSE
c
Male
c
Female
DEPENDENT 1
c
Male
c
Female
DEPENDENT 2
c
Male
c
Female
Your legal spouse and dependent(s) are eligible for coverage under this plan. Federal law requires the Plan to have on le the full name, Social Security
number, gender, and date of birth of all covered individuals. You may cancel legal spouse and dependent coverage only in the event of a divorce or legal
separation, by submitting a COBRA Event Notice form. Forms are available after logging in at veba.org or by request from the customer care center. List
any additional dependents on an attached sheet of paper.
UPDATE PARTICIPANT CONTACT INFORMATION | CHANGE NAME
1
ADD/UPDATE LEGAL SPOUSE DEPENDENT INFORMATION
2
REQUIRED PARTICIPANT SIGNATURE CERTIFICATION
3
LAST NAME
ACCOUNT NUMBER or SSN DATE OF BIRTH MM / DD / YYYY
FIRST NAME M.I.
c
YES
c
NO
NAME EXACTLY AS IT APPEARS ON SOCIAL SECURITY CARD or MEDICARE CARD
MEDICARE ID NUMBER (HICN) PART A EFFECTIVE DATE PART B EFFECTIVE DATE
Your handwritten signature is required; e-signatures are not acceptable.
X
PARTICIPANT SIGNATURE DATE MM / DD / YYYY PHONE NUMBER WHERE I CAN BE REACHED
I hereby certify that the information provided on this form is true and correct. With respect to information submitted on behalf of qualified dependents, I hereby
certify that each person is a qualified dependent as defined under the terms of the Plan. I acknowledge and understand that any information submitted
fraudulently could result in my termination from the Plan and/or other legal action.
Please check the box and enter your email address above to sign-up for e-communication.
E-communication is fast and convenient. Electronic documents may include your Plan Summary, participant account statement and explanation of
benets (EOB) notications, and general communication. If you are electing e-communication, please note that after logging in to your account at
veba.org, you (1) may withdraw your consent for electronic documents at any time without charge by updating your account preferences; (2) will be
able to view and print copies of electronic documents (you may request paper copies at no charge by contacting the customer care center); and (3)
can update your email address on le by updating your personal information. To access electronic documents, you will need a copy of Adobe Acrobat
Reader software loaded on your computer. You can download and install a free copy at www.adobe.com. Documents provided electronically will not
be mailed via U.S. Mail.
MAILING ADDRESS CITY STATE ZIP
AREA CODE and PHONE NUMBER EMAIL ADDRESS (use home or personal email address)
EMPLOYER NAME
DATE OF SEPARATION OR RETIREMENT MM / DD / YYYY
c
YES
c
NO
VP11 (12/14 PRC)
1-888-828-4953 | |
Skip this form! Log in at and submit your account change online.
| Fax: (206) 577-3020 | VEBA Plan, PO Box 80587, Seale WA 98108
