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.

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.

The 2027 PEBB Employee Enrollment/Change form. Use this form to enroll in or make changes to your benefits.

The 2027 PEBB Employee Enrollment/Change form for Medical Only groups. Use this form to enroll in or make changes to your benefits.

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

2026 PEBB Retiree Election Form (form A). Use Form A to enroll in PEBB retiree coverage.

Use Form A: Retiree Election Form if you are a new retiree or surviving dependent who wants to enroll in or defer PEBB retiree coverage. You can also use Form A if you are enrolling after deferring coverage.

Return this form and any supporting documents including proof of Medicare no later than 60 days after other qualifying coverage ends.

2026 PEBB Medicare Plan Disenrollment Form. Use this form to disenroll from a Medicare Advantage with Part D plan or UMP Classic Medicare with Part D.

2026 PEBB Retiree Change Form. Use Form E to make changes to your PEBB retiree coverage.