Retiree Change Form (form E) 2021

51-0007

Use Form E to make changes to your PEBB retiree insurance coverage.

Form

Retiree Election Form (form A) 2021

51-4031

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 hca.wa.gov/coronavirus.

Form

UMP (Regence) Medical incident report

This form is to report to Regence if an injury or illness may be covered under a third party. You may need to use this form even if the incident is not subject to third party coverage.

Form