Retiree Election Form (form A) 2022


This is the 2022 Retiree Election Form (form A). Use this form to elect PEBB Retiree insurance coverage. To make changes to your retiree insurance coverage, use the 2022 Retiree Coverage Change Form (form E). Due to the COVID-19 pandemic, the PEBB Program has temporarily changed the deadline to enroll in PEBB retiree insurance coverage when first eligible. To learn more about this exception to the timelines listed in this document, visit HCA's website at