Forms & publications

Can't find what you need? Visit UMP Forms and publications for more documents.

2017-2018 comparison of UMP monthly premiums

This document lists the 2017 and 2018 monthly premiums for UMP members who are employees and retirees.

Publication

2018-2019 comparison of UMP monthly premiums

This document lists the 2018 and 2019 monthly premiums for UMP members who are employees and retirees.

Publication

Certification of a child with disability (PEBB) 2020

50-142

After 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.

Form

Declaration of tax status (PEBB) 2019

50-704-2019

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

Declaration of tax status (PEBB) 2020

50-704

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

Delta Dental (DeltaCare and Uniform Dental Plan) (PEBB) 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.

Publication

DeltaCare (PEBB) Certificate of Coverage (COC) 2019

This benefits book describes what is covered under DeltaCare, including dental services as well as specific services not covered by the plan, finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays. It also includes how to request an appeal and how to submit a claim.

Publication

DeltaCare (PEBB) Certificate of Coverage (COC) 2020

This benefits book describes what is covered under DeltaCare, including dental services as well as specific services not covered by the plan, finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays. It also includes how to request an appeal and how to submit a claim.

Publication

Electronic debit service (EDS) agreement 2020

Electronic Debit Service (EDS) is only available to continuously enrolled self-pay PEBB subscribers. Electronic service allows PEBB subscribers to have monthly payments automatically taken from a checking or savings account.

Form

Electronic debit service agreement

42-450

Electronic Debit Service (EDS) is only available to continuously enrolled self-pay PEBB subscribers. Electronic service allows PEBB subscribers to have monthly payments automatically taken from a checking or savings account.

Form

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