Forms & publications

Retiree Election Form (form A) 2024

This is the 2024 Retiree Coverage Election Form (form A). Use this form to enroll in PEBB Retiree insurance coverage. To make changes to your retiree insurance coverage, use the 2024 Retiree Coverage Change Form (form E).

Spousal Plan Calculator (SEBB) 2024 (pdf)

This is the 2024 SEBB Spousal plan calculator form. Use this form if you answered 'YES' to all the questions on your enrollment form and are wanting to enroll a spouse or state-registered domestic partner.

Spousal Plan Calculator Form (PEBB) 2024 (pdf)

This is the 2024 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions on your enrollment form and are enrolling a spouse or state-registered domestic partner.

Spousal Surcharge Calculator Tool (PEBB) 2024 (xls)

This is the 2024 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions on your enrollment form and are enrolling a spouse or state-registered domestic partner.

Spousal Surcharge Calculator Tool (SEBB) 2024 (xls)

This is the 2024 SEBB Spousal plan calculator form. Use this form if you answered 'YES' to all the questions on your enrollment form and are wanting to enroll a spouse or state-registered domestic partner.