Form A: Retiree Election Form 2026
2026 PEBB Retiree Election Form (form A). Use Form A to enroll in PEBB retiree coverage.
Forms & publications
Form A: Retiree Election Form 2027
Use Form A: Retiree Election Form if you are a new retiree or surviving dependent who wants to enroll in or defer PEBB retiree coverage. You can also use Form A if you are enrolling after deferring coverage.
Return this form and any supporting documents including proof of Medicare no later than 60 days after other qualifying coverage ends.
Return this form and any supporting documents including proof of Medicare no later than 60 days after other qualifying coverage ends.