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Forms & publications
Can't find what you need? Visit UMP Forms and publications for more documents.
SEBB benefits preview article
An article for the February 2019 SEBB member toolkit on medical, dental, vision and other SEBB Program benefits.
Fact sheetCensus data spreadsheet
Spreadsheet for employers to share demographic data
FormCertification of a child with disability 2019
50-142-2019After turning 26, your dependent may be eligible for enrollment under your PEBB coverage. Use this form to certify your dependent's disability and enroll them on your PEBB coverage.
FormCertification of dependent with a disability 2018
50-142-2018After 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.
FormCOBRA and Continuation Coverage monthly premiums 2018
2018 Monthly premiums for PEBB COBRA and Continuation Coverage (LWOP).
PublicationCOBRA election/change form (continuation of coverage) 2018
50-245F-2018Use this form to enroll in or change your enrollment options for COBRA coverage.
FormContinuation Coverage Election Notice
50-801This 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.
PublicationContinuation coverage election/change form (for Leave Without Pay) 2018
50-135F-2018Use this form to enroll in or change your enrollment options for continuation coverage (LWOP).
FormDeclaration of tax status 2018
50-704-2018Employees 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.
FormDeclaration of tax status 2019
50-704-2019Employees 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.
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