Forms & publications

Appointed and Elected Officials Transitioning Out of Office

56-023

General information and requirements for PEBB benefits for appointed and elected officials who are transitioning out of office.

Publication

Census data spreadsheet

Spreadsheet for employers to share demographic data

Form

Certification of dependent with a disability 2017

50-142-2017

After turning 26, your dependent may be eligible for enrollment under your PEBB medical. Use this form to certify your dependent's disability and enroll them on your PEBB medical.

Form

COBRA and Continuation Coverage monthly rates 2017

50-300R

2017 Monthly rates for PEBB COBRA and Continuation Coverage (LWOP).

Publication

COBRA election/change form (continuation of coverage) 2017

50-245F-2017

Use this form to enroll in or change your enrollment options for COBRA coverage.

Form

Completing the Retiree Forms

51-403P_2016.pdf

Use this as a guide when completing retiree forms.

Publication

Continuation Coverage Election Notice

50-801

This is the booklet you will receive when your Public Employees Benefits Board (PEBB) health coverage ends. This booklet explains how you and your dependents can continue your PEBB health coverage. To continue PEBB health coverage, you must complete the enclosed form(s) and follow the instructions.

Publication

Continuation coverage election/change form (for Leave Without Pay) 2017

50-135F-2017

Use this form to enroll in or change your enrollment options for continuation coverage (leave without pay).

Form

Continuing Benefits after Layoff

56-021

Information and resources on how to continue PEBB benefits after a layoff.

Publication

Declaration of tax status 2017

50-704-2017

Employees and retirees must complete and submit this form with their enrollment form when enrolling an individual on their PEBB Program coverage who does not qualify as their dependent for federal tax purposes.

Form

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