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How to complete the 2018 Retiree Election/Change form (Form A)

This document helps you complete Form A. These are instructions only. Do not return.

Fact sheet

Retiree coverage election form (form A) 2019

51-403F-2019

This is the 2019 Retiree Coverage Election Form (form A). Use this form to elect Retiree insurance coverage. To make changes to your retiree insurance coverage, use the 2019 Retiree Coverage Change Form (form E).

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