Forms & publications

Retiree Enrollment Form (form A) 2023

This is the 2023 Retiree Coverage Election Form (form A). Use this form to elect PEBB Retiree insurance coverage. To make changes to your retiree insurance coverage, use the 2023 Retiree Coverage Change Form (form E).

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.