Forms & publications

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COBRA election/change form (continuation of coverage) 2018

50-245F-2018

Use this form to enroll in or change your enrollment options for COBRA coverage.

Form

Continuation coverage election/change form (for Leave Without Pay) 2018

50-135F-2018

Use this form to enroll in or change your enrollment options for continuation coverage (LWOP).

Form

PEBB Continuation Coverage (COBRA) election/change form 2019

50-245F-2019

Use this form to enroll in or change your enrollment options for COBRA coverage.

Form

PEBB Continuation Coverage (Unpaid Leave) election/change form 2019

50-135F-2019

Use this form to enroll in or change your enrollment options for PEBB Continuation Coverage (Unpaid Leave).

Form

Premium Payment Plan Election/Change Form

50-185

Complete this form if you do not want to pay your medical premiums with pretax earnings.

Form

Retiree coverage election/change (Form A) 2018

51-403F

This is the form to change Retiree medical coverage. This form is also used to enroll in or defer PEBB Retiree medical coverage.

Form