Forms & publications

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.

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.

Use this form to have your employer withhold money from your paychecks and deposit it into your health savings account (HSA) on a pretax basis. Check with your payroll department before submitting this form; not all employers can arrange for payroll deductions. You must be enrolled in a consumer-directed health plan (CDHP) with an HSA before you can start a payroll deduction.

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

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.

Submit this form with your enrollment form if you are enrolling an extended (legal) dependent child.

Use this form to name the persons or entities you want to receive your life insurance proceeds after your death. Return this form to MetLife.

Use this form to notify MetLife that you wish to cancel your Supplemental Life Insurance and/or Supplemental Accidental Death & Dismemberment (AD&D) Insurance. For employees only: Employee Basic Life Insurance ($35,000) and Employee Basic AD&D Insurance ($5,000) is not affected by this form. It is provided by your employer at no cost to you. You cannot cancel your Employee Supplemental Life Insurance and keep Dependent Life Insurance.

Use this form if you are requesting an appeal of a decision.

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