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Forms & publications
Can't find what you need? Visit UMP Forms and publications for more documents.
Census 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.
FormDelta Dental (DeltaCare and Uniform Dental Plan) preauthorization requirements
Preauthorization requirements for DeltaCare and Uniform Dental Plan (administered by Delta Dental of Washington). Preauthorization is when you seek approval from your health plan for coverage of specific services, supplies, or drugs before receiving them. Some services or treatments (except emergencies) may require preauthorization before the plan pays for them. These criteria do not imply or guarantee approval. Please check with your plan to ensure coverage. Preauthorization requirements are only valid for the month published. They may have changed from previous months and may change in future months.
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