Certification of a Child with Disability (PEBB) 2021

50-0142

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.

Form

Extended Dependent Certification (PEBB) 2021

50-0500

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

Form