PEIA Online Enrollment Signup Form
Plan Year 2007
Please type in this information, then print and mail the form to PEIA at the address below.
City: State: Zip:
Policyholder’s e-mail address:
PEIA will use this e-mail address to communicate with you during the open enrollment.
By signing below, I agree to be bound by the choices I make on PEIA’s Open Enrollment
Website during the Open Enrollment period (April 3 – May 5, 2006) for Plan Year 2007 (July 1,
2006- June 30, 2007), unless I experience a qualifying event. I understand that PEIA will not
mail me a hard-copy transfer form, unless I request one during open enrollment. I agree to
visit the PEIA Open Enrollment Website during the open enrollment period to complete my
tobacco affidavit and make any desired plan changes. I understand and agree that if I sign up
to use the PEIA Open Enrollment Website, but make no benefit changes during the Plan Year
2007 Open Enrollment, I will be bound by the benefit selections I made last year (no change)
and that my tobacco affidavit will expire, so I will lose any tobacco-free premium discount I
may be receiving.
I further agree that by signing this form I am agreeing to use a digital mark in lieu of a written
signature. To use this digital mark I agree:
1. That I will not share with any other person the password, code or other security key
required for use of the mark;
2. That the use of the mark represents confirmation of a record;
3. To notify the PEIA immediately once I become aware that the security key is
4. That I understand that the provisions of W. Va. Code §61-3C-10 prescribe the penalties
for the unauthorized disclosure of a password, identifying code, personal
identification number or other confidential security information.
Policyholder Signature __________________________________ Date__________________
To participate in the online enrollment, you must sign and return this Online
Enrollment Signup Form postmarked no later than February 15, 2006. Mail your
PEIA Online Enrollments
State Capitol Complex, Bldg 5, Rm. 1001
1900 Kanawha Blvd. E
Charleston, WV 25305-0710