Forms & publications

After turning 26, your dependent may be eligible for enrollment under your PEBB coverage. Use this form to certify your dependent's disability and enroll them on your PEBB coverage.

Employees and retirees must complete and submit this form with their enrollment form when enrolling an individual on their PEBB Program coverage who does not qualify as their dependent for federal tax purposes.

Use this form to enroll in or make changes to PEBB benefits for you or your dependents.

Use this form to enroll in or make changes to PEBB Program benefits for you or your dependents.

Use this form to enroll in or make changes to PEBB benefits for you and your dependents if your employer offers medical coverage only.

Use this form to enroll in or make changes to PEBB Program benefits for you and your dependents if your employer offers PEBB Program medical coverage only.

Submit this form with your enrollment form if you are enrolling an extended (legal) dependent child.

Use this form to enroll in or change your enrollment options for COBRA coverage.

Use this form to enroll in or change your enrollment options for PEBB Continuation Coverage (Unpaid Leave).

Use this form to enroll in or change your enrollment options for COBRA coverage.