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Change Application Form

Please use this form to change address information, add and delete dependants, or change benefit coverage. ASEBP will also use this form to advise of name changes.

Please Note:

  1. Please contact your employer to determine which sections of the form you need to complete.
  2. Upon completion, submit the original form directly to your employer.**
  3. Faxed, photocopied, or scanned forms will be returned to you.

**If you are an early retiree or have been receiving Extended Disability Benefits for more than 24 months, then please submit directly to ASEBP.

Download the Change Application form.