Find a Form or Document

The following is an alphabetical list of forms and documents on the Web site.

If you see (Complete Online) next to a form, you can do this online by going to Manage My Benefits. It's easier, faster and leads to fewer mistakes than printing a form and sending it to PEIA.

***If you have previously had PEIA as your insurance carrier, you are unable to use Manage My Benefits to log in and enroll.
Please see your HR department to fill out paper enrollment forms.

Forms

ABA Services Preauthorization Form

Annual Routine Physical and Screening Examination Form

Authorization to Release/Disclose Form

Authorization to Remove Coordinator Form

Basic and/or Optional Life Insurance Change of Beneficiary

Basic Life (Complete Online)

Change-in-Address Form (Complete Online)

Change-in-Status Form (Complete Online)
Please note, to update your Mountaineer Flexible Benefits elections after a change-in-status event, you must complete an Enrollment Form with FBMC. Employees must submit the form, as well as supporting documentation, to their Agency Benefit Coordinator within the month of or two months following the status-changing event. Please visit https://peia.wv.gov/Forms-Downloads/Pages/Mountaineer-Flexible-Benefits.aspx to download the appropriate Enrollment form.

Combined Leave Form

Comprehensive Care Program Enrollment Form

Coordination of Benefits (Form no longer required, call UMR at 1-888-440-7342 to update information)

Dependent Documentation Memo

Direct Draft Form

Disabled Dependent Eligibility Application

Electronic Funds Transfer Form

Health Benefits Enrollment Form (Complete Online)

HealthCheck Forms

Maternity Benefit Pre-Payment Form

Medical Claim Form

Medical Travel Expense Reimbursement Request Form