Retiree Election Form (form A) 2021


This is the 2021 Retiree Election Form (form A). Use this form to elect PEBB Retiree insurance coverage. To make changes to your retiree insurance coverage, use the 2020 Retiree Coverage Change Form (form E). Due to the COVID-19 pandemic, the PEBB Program has temporarily changed the deadline to enroll in PEBB retiree insurance coverage when first eligible. To learn more about this exception to the timelines listed in this document, visit HCA's website at