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Employees (with both medical and dental coverage)
- Watch how to complete the form when enrolling in Long Term Disability no later than 31 days from date of eligibility
- Watch how to complete the form when making changes or enrolling in Long Term Disability after the first 31 days of eligibility
- Learn how to determine your eligibility for PEBB coverage
Retirees
- New Retirees - Learn how to apply for retiree health coverage
- Current Retirees - Find the correct form(s) to make changes due to a qualifying event
Employee
Employee Enrollment/Change (372 KB)- Employee Enrollment/Change for Medical Only Groups (709.6 KB)
- Life and AD&D Insurance Enrollment/Change (105.5 KB)
- Life Insurance Evidence of Insurability (452 KB)
- Long Term Disability Evidence of Insurability Form (186.6 KB)
- Long-Term Disability Enrollment/Change (81.5 KB)
Premium Payment Plan Election/Change (51.4 KB)
Retiree
- Medicare Advantage Plan Disenrollment (Form D) (166.8 KB)
- Medicare Advantage Plan Election (Form C) (444 KB)
- Medicare Supplement Enrollment (Form B) (157.8 KB)
- Retiree Coverage Election (Form A) (479.8 KB)
Dependent Certification
- Declaration of Tax Status (233.4 KB)
- Dependents with Disabilities (279 KB)
- Extended (Legal) Dependents (226.7 KB)
Continuation of Coverage
- COBRA Continuation of Coverage Election (447.4 KB)
- Group Life Portability Application (61.8 KB)
- Leave Without Pay (390.6 KB)
Miscellaneous
- Authorization for Release of Information (29.2 KB)
Change in Beneficiary (Employees: Submit to your payroll office)- Electronic Debit Service Agreement (147.5 KB)
- Employee Authorization for Payroll Deduction to Health Savings Account (42.9 KB)
- Non-Smoker Certification (Amendment to Original Application) (65.5 KB)
- Request for Review/Notice of Appeal (50.8 KB)
