Forms & publications

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

COBRA election/change form (continuation of coverage) 2018

50-245F-2018

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

Form

Continuation coverage election/change form (for Leave Without Pay) 2018

50-135F-2018

Use this form to enroll in or change your enrollment options for continuation coverage (LWOP).

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

Employee enrollment/change for medical groups only 2019

52-030-2019

Use this form to enroll in or make changes to PEBB Program benefits for you and your dependents if your employer offers PEBB Program medical coverage only.

Form

Employee enrollment/change form 2018

50-400-2018

Use this form to enroll in or make changes to PEBB Program benefits for you or your dependents.

Form

Employee enrollment/change form 2019

50-400-2019

Use this form to enroll in or make changes to PEBB Program benefits for you or your dependents.

Form

Employee enrollment/change form medical groups only 2018

52-030-2018

Use this form to enroll in or make changes to PEBB Program benefits for you and your dependents if your employer offers PEBB Program medical coverage only.

Form

Medicare advantage disenrollment form (Form D) 2018

51-556-2018

Use this form to disenroll from Medicare Advantage plans.

Form

Medicare Advantage disenrollment form (form D) 2019

51-556-2019

Use this form to disenroll from Medicare Advantage.

Form

Medicare advantage plan election form (Form C) 2018

51-576-2018

Use this form to enroll in Medicare Advantage plans.

Form

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