See forms for:

 

  

Employee forms

Enrollment/changes

  • Employee Enrollment/Change  2014  |  2015
  • Employee Enrollment/Change for Medical Only Groups  2014  |  2015
  • Premium Payment Plan Election/Change  2014  |  2015

Flexible spending arrangement (FSA) and Dependent Care Assistance Program (DCAP)

Health savings account (HSA) 

  • Employee Authorization for Payroll Deduction to Health Savings Account  2014  |  2015
  • Health Savings Account Beneficiary Designation  2014  |  2015

Life and accidental death and dismemberment (AD&D) insurance

  • Life and AD&D Insurance Enrollment/Change  2014  |  2015
  • Life Insurance Evidence of Insurability  2014  |  2015
  • Life Insurance Beneficiary Designation (submit to your payroll office)  2014  |  2015
  • Life Insurance Non-Smoker Certification (Amendment to Original Application; not for premium surcharge attestation)

Note: Life insurance portability forms are available through your employer.

Long-term disability (LTD)

  • Long-Term Disability Enrollment/Change  2014  |  2015
  • Long-Term Disability Evidence of Insurability  2014  |  2015
   

Retiree forms 

Enrollment/changes

Health savings account (HSA)

  • Health Savings Account Beneficiary Designation  2014  |  2015

Life insurance

  • Life Insurance Beneficiary Designation  2014  |  2015
  

Continuation of coverage forms

For COBRA, Leave Without Pay (LWOP), and PEBB Extension of Coverage

Enrollment/changes

  • COBRA Continuation of Coverage or PEBB Extension of Coverage Election/Change  2014  |  2015
  • Leave Without Pay Election/Change  2014  |  2015
  • Electronic Debit Service Agreement  2014  |  2015
  • Health Savings Account Beneficiary Designation  2014  |  2015  
 

Dependent certification forms

For enrolling a registered domestic partner, a domestic partner's child, a dependent child with a disability, or an extended legal dependent child. 

Enrollment/changes

  • Declaration of Tax Status  2014  |  2015
    To enroll a registered domestic partner or a registered domestic partner's child
  • Certification of Dependent With a Disability  2014  |  2015
    To enroll a dependent child with a disability (over age 26)
  • Extended Dependent Certification  2014  |  2015
    To enroll an extended (legal) dependent child  
   

Attestation forms

For 2014 attestations/changes​​

For 2015 attestations/changes​​​

Note: There are fewer attestation forms for 2015 than 2014.

 


Privacy and appeals

Privacy

  • Authorization for Release of Information  2014  |  2015

Appeals

  • Request for Review/Notice of Appeal  2014  |  2015