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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

Use this form to enroll in PEBB retiree insurance coverage.

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