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.

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.

PEBB Electronic Debit Service (EDS) is only available to retirees and continuation coverage subscribers. Electronic service allows PEBB subscribers to have monthly payments automatically taken from a checking or savings account.

Use this form to have your employer withhold money from your paychecks and deposit it into your health savings account (HSA) on a pretax basis. Check with your payroll department before submitting this form; not all employers can arrange for payroll deductions. You must be enrolled in a consumer-directed health plan (CDHP) with an HSA before you can start a payroll deduction.

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 Program benefits for you or your dependents.

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.

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

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