Forms & publications

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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

Retiree coverage change form (form E) 2019

51-0007-2019

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

Form

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