Forms & publications

Complete this form if you do not want to pay your medical premiums with pretax earnings.

This is the 2025 PEBB Premium Surcharge Attestation Change form. Use this form to report a change that affects your surcharge for tobacco use and/or spouse or state-registered domestic partner coverage.

This is the 2025 SEBB Premium Surcharge Attestation Change form. Use this form to report a change that affects your surcharge for tobacco use and/or spouse or state-registered domestic partner coverage.

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

This is the 2025 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 2025 Retiree Coverage Change Form (form E).

This is the 2025 Retiree Enrollment Guide. It contains information you need about enrollment, eligibility, benefits, monthly premiums, and the plans available to retirees.

These are the PEBB retiree premiums for retirees in 2025. These premiums do not include the monthly premium surcharges, if applicable to your account.

Use this form if you are requesting an appeal of a decision.

School board members use this form to enroll in your SEBB insurance coverage.

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 high deductible health plan with an HSA before you can start a payroll deduction.