Fillable Printable Name And Address Change Form
Fillable Printable Name And Address Change Form
Name And Address Change Form
Universal Name/Address Change Form
A copy of a Social Security card is required for a name change.
PRINT OR TYPE - USE BLACK INK. Type of subscriber (check one):
TYPE OF CHANGE (check all that apply):
____ Name _____ Marriage _____ Divorce _____ Address
1. SOCIAL SECURITY # ____________ - __________ - ____________ OR Benets Identication # ____________________________________
2. NAME __________________________________________________ _________ ______________________________________________
First MI Last
3. STREET _____________________________________________________________________________________ Apt. # __________________
4. CITY ________________________________________________________________ STATE ____________ ZIP CODE ___________________
5. HOME PHONE ( ) ___________ - ___________ WORK PHONE ( ) ___________ - ____________ COUNTY CODE ___________
6. EMAIL ADDRESS _________________________________________________________________________
7. PREVIOUS NAME (if applicable)
________________________________________________________ _________ _______________________________________________
First MI Last
8. PREVIOUS ADDRESS (if applicable)
STREET_________________________________ Apt. # ____________ CITY ___________________ STATE _____ ZIP CODE ___________
Distribution:
• Human Resource Ofce • PEBA Insurance Benets • PEBA Retirement Benets
P.O. Box 11661 P.O. Box 11960
• Payroll Columbia, SC 29211 Columbia, SC 29211-1960
PEBA Insurance Benets Group No. ________________________________________
__________________________________________________________ ________________________
Group Name Effective Date
Active COBRA
Retired Survivor
Universal Name Change Form (Rev. 5/2013)
_________________________________________________________ ________________________________________
SUBSCRIBER SIGNATURE DATE
_________________________________________________________ ________________________________________
BENEFITS ADMINISTRATOR SIGNATURE (if applicable) DATE
