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Employees
- Watch how to complete the Life Insurance Enrollment Form
- 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 eligibilty 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 (435 KB)- Employee Enrollment/Change for Medical Only Groups (583.5 KB)
- Life and AD&D Insurance Enrollment/Change - For current employees to use starting March 1, 2012, or new employees to use within initial eligibility period (149.3 KB)
- Life and AD&D Insurance Special Reenrollment - For current employees to use February 1-29, 2012 (157 KB)
- Life Insurance Evidence of Insurability (97.7 KB)
- Long Term Disability Enrollment/Change (62.1 KB)
- Long Term Disability Evidence of Insurability (213.7 KB)
Premium Payment Plan Election/Change (42.9 KB)
Retiree
- Medicare Advantage Plan Disenrollment (Form D) (256.4 KB)
- Medicare Advantage Plan Election (Form C) (296 KB)
- Medicare Supplement Enrollment (Form B) (157.8 KB)
- Retiree Coverage Election (Form A) (573.3 KB)
Dependent Certification
- Declaration of Tax Status (240.4 KB)
- Dependents with Disabilities (297 KB)
- Extended (Legal) Dependents (290.2 KB)
Continuation of Coverage
- COBRA Continuation of Coverage Election (573.7 KB)
- Group Life Portability Application (66.3 KB)
- Leave Without Pay (521.2 KB)
Miscellaneous
- Authorization for Release of Information (36.1 KB)
Change in Beneficiary (Employees: Submit to your payroll office)- Electronic Debit Service Agreement (123.2 KB)
- Employee Authorization for Payroll Deduction (103.6 KB)
- Non-Smoker Certification (Amendment to Original Application) (50.5 KB)
- Request for Review/Notice of Appeal (244.3 KB)
