Use 2015 forms for enrollment or changes effective in 2015.

Use 2016 forms for open enrollment changes effective January 1, 2016.

See forms for:

Employee forms


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

Health savings account (HSA)

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

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

Long-term disability (LTD)

Retiree forms


Health savings account (HSA)

Life insurance

Continuation of coverage forms

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


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.


Surcharge attestation forms

  • Premium Surcharge Change  2015  |  2016 
    To make changes to your tobacco use or spousal coverage attestations
  • Premium Surcharge Help Sheet  2015  |  2016
  • Spousal Plan Calculator (print version)  2015  |  2016

Release of private information