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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


Use this form to enroll in PEBB retiree insurance coverage.


Retiree coverage election/change (Form A) 2018


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