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Certification of a Child with a Disability (PEBB) 2022
50-0142After 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.
FormExtended Dependent Certification (PEBB) 2022
50-0500Submit this form with your enrollment form if you are enrolling an extended (legal) dependent child.
Form