"Change in Address Form" - West Virginia

Change in Address Form is a legal document that was released by the West Virginia Public Employees Insurance Agency - a government authority operating within West Virginia.

Form Details:

  • Released on August 1, 2017;
  • The latest edition currently provided by the West Virginia Public Employees Insurance Agency;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the West Virginia Public Employees Insurance Agency.

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State of West Virginia Public Employee Insurance Agency
CIA
Change In Address Form
Complete this form to Change the Address for you or your dependents.
Please Note: Changing your address with PEIA does not update the information with Mountaineer
Flexible Benefits. You must also complete a Demographic Change form and send it to FBMC to update
your information in their system.
Full Legal Name (Last)
(First)
(MI)
(Generation: Jr., Sr., etc.)
Social Security Number
Old Mailing Address
County of Residence
Home Telephone
(
)
City
State
Zip
Work Telephone
(
)
Physical Address
Sex (Circle one)
M
F
City
State
Zip
Date of Birth (mm/dd/yy)
New Mailing Address
County of Residence
City
State
Zip
Physical Address
City
State
Zip
Legal Name
New Address
(Last, First, MI,Generation)
(if different from above)
Agency Name
I hereby certify that to the best of my knowledge, the information contained herein is accurate and that providing false
information on this form is illegal and those who provide false information may be prosecuted.
Policyholder’s Signature:
Date:
th
Mail to: PEIA 601 57
Street SE Charleston, WV 25304
August 2017
State of West Virginia Public Employee Insurance Agency
CIA
Change In Address Form
Complete this form to Change the Address for you or your dependents.
Please Note: Changing your address with PEIA does not update the information with Mountaineer
Flexible Benefits. You must also complete a Demographic Change form and send it to FBMC to update
your information in their system.
Full Legal Name (Last)
(First)
(MI)
(Generation: Jr., Sr., etc.)
Social Security Number
Old Mailing Address
County of Residence
Home Telephone
(
)
City
State
Zip
Work Telephone
(
)
Physical Address
Sex (Circle one)
M
F
City
State
Zip
Date of Birth (mm/dd/yy)
New Mailing Address
County of Residence
City
State
Zip
Physical Address
City
State
Zip
Legal Name
New Address
(Last, First, MI,Generation)
(if different from above)
Agency Name
I hereby certify that to the best of my knowledge, the information contained herein is accurate and that providing false
information on this form is illegal and those who provide false information may be prosecuted.
Policyholder’s Signature:
Date:
th
Mail to: PEIA 601 57
Street SE Charleston, WV 25304
August 2017