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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.
FormCertification of a Child with a Disability (SEBB) 2022
20-0061After turning 26, your dependent may be eligible for enrollment under your SEBB coverage. Use this form to certify your dependent's disability and enroll them on your SEBB coverage.
FormExtended Dependent Certification (PEBB) 2022
50-0500Submit this form with your enrollment form if you are enrolling an extended (legal) dependent child.
FormExtended Dependent Certification (SEBB) 2022
20-0084Submit this form with your enrollment form if you are enrolling an extended (legal) dependent child.
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