Employee enrollment/change for medical groups only (PEBB) 2020

52-030

Use this form to enroll in or make changes to PEBB Program benefits for you and your dependents if your employer offers PEBB Program medical coverage only.

Form

Employee enrollment/change form (PEBB) 2020

HCA 50-400

Use this form to enroll in or make changes to PEBB Program benefits for you or your dependents.

Form

MetLife employee enrollment/change form (PEBB) 2020

Use this form to enroll in or change enrollment in basic life and AD&D insurance, as well as optional life, and/or AD&D insurance for yourself and your dependents. You may need to complete a statement of health. Return this form to MetLife.

Form