Employee Enrollment/Change Form (PEBB) 2021

50-0400

Use this form to enroll in or make changes to PEBB benefits for you or your dependents. Due to the COVID-19 pandemic, employees who are hired (or return to work) at a state agency in jobs that respond to the state of emergency may be able to get PEBB coverage sooner than normal. To learn more about this exception to the timelines listed in this document, visit HCA's website at hca.wa.gov/coronavirus.

Form

Employee Enrollment/Change Form Medical Only (PEBB) 2021

52-0030

Use this form to enroll in or make changes to PEBB benefits for you and your dependents if your employer offers medical coverage only. Due to the COVID-19 pandemic, employees who are hired (or return to work) at a state agency in jobs that respond to the state of emergency may be able to get PEBB coverage sooner than normal. To learn more about this exception to the timelines listed in this document, visit HCA's website at hca.wa.gov/coronavirus.

Form