Forms & publications

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

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.

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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 2019

50-400-2019

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

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) 2019

51-576-2019

Use this form to enroll in Medicare Advantage plans.

Form

MetLife retiree enrollment/change form

Use this form to enroll in or change enrollment in retiree term life insurance through MetLife.

Form

PEBB Continuation Coverage (Unpaid Leave) election/change form 2019

50-135F-2019

Use this form to enroll in or change your enrollment options for PEBB Continuation Coverage (Unpaid Leave).

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Premera Medicare supplement plan F enrollment form (Form B)

Use this form to enroll in Medicare Supplemental insurance administered by Premera.

Form

Premium Payment Plan Election/Change Form

50-185

Complete this form if you do not want to pay your medical premiums with pretax earnings.

Form

Retiree coverage election form (form A) 2019

51-403F-2019

This is the 2019 Retiree Coverage Election Form (form A). Use this form to elect Retiree insurance coverage. To make changes to your retiree insurance coverage, use the 2019 Retiree Coverage Change Form (form E).

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