Forms & publications

Can't find what you need? Visit UMP Forms and publications for more documents.

Employee enrollment/change form 2019

50-400-2019

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

Form

Employee monthly premiums 2019

These are the Public Employee Benefits Board (PEBB) Program medical plans offered for 2019. These premiums apply to employees in state agencies, higher-education institutions, and community and technical colleges. These premiums do not include the monthly premium surcharges, if applicable to your account.

Publication

Employee Request for Review/Notice of Appeal form

50-122

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

Form

Employer Group application deadlines 2019

2019 deadlines for the employer groups application.

Publication

Employer Group Attestation

Political subdivisions, tribal governments, K-12 school districts, and educational service districts that are applying to participate in PEBB must sign the following attestation language attesting to the fact that the employees and all departments or agencies of the applying group fulfill government functions for the citizens of Washington

Form

Employer Group Monthly Cost Tool 2019

Use this to help you project or estimate your group's total cost for PEBB benefits for a month.

Form

Extended dependent certification 2019

50-500-2019

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

Form

FAQs: New Medicare cards

FAQs for new Medicare cards for PEBB members.

Fact sheet

For Your Benefit (2017-09)

This is the September 2017 For Your Benefit newsletter for all PEBB members.

Newsletter

For Your Benefit (2018-02)

The February 2018 edition of PEBB's For Your Benefit newsletter.

Newsletter

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