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Enroll as a survivor
If you are a survivor of an eligible employee, retiree, or emergency service personnel killed in the line of duty, this page will help you understand what you need to due and by when to enroll in PEBB retiree insurance coverage.
You will need to submit Retiree Election Form A (form A) to enroll in coverage, along with any other forms and documents based on your situation.
Looking for answers to eligibility questions? Visit Are my survivors eligible? Need to defer coverage? Visit Defer as a survivor.
On this page
For survivors of eligible employees and retirees
When an employee or retiree passes away, their spouse, state-registered domestic partner, or child who loses eligibility due to the death may enroll in or defer PEBB retiree insurance coverage as a survivor.
What do I do?
An enrolled dependent of a retiree who passed away, will need to notify the PEBB Program of your loved one's death. We will automatically move you to your own account.
A survivor of an eligible employee or retiree who was not enrolled in PEBB retiree insurance coverage when they passed away must submit:
- Retiree Election Form A (form A)
- Any other required forms and documents based on your situation
Note: If you are a survivor of a retiree who deferred PEBB retiree insurance coverage, you must also provide proof of continuous enrollment in qualifying medical coverage from the most recent open enrollment for which you were not enrolled in a PEBB medical plan before the retiree's death.
By when?
The PEBB Program must receive your forms and documents within the following timelines. For eligible survivors of an:
Employee
No later than 60 days after the date of your loved one's death or the date your PEBB, SEBB, or educational service district insurance coverage ends, whichever is later.
Retiree
No later than 60 days after the date of your loved one's death.
Elected or full-time appointed official
No later than 60 days after the date of your loved one's death or the date your PEBB insurance coverage ends, whichever is later.
Exceptions to the 60-day timeline
Earlier deadlines apply if you enroll in a Medicare Advantage or Medicare Advantage Prescription Drug plan. Learn more about Medicare and PEBB benefits.
For survivors of emergency service personnel
What do I do?
To enroll in PEBB retiree insurance coverage, you must submit:
- Retiree Election Form (form A)
- Any other required forms or documents based on your situation
By when?
The PEBB Program must receive your forms and documents no later than 180 days after the later of these events:
- The death of your loved one.
- The date on the letter from the Department of Retirement Systems (DRS) or the Board for Volunteer Firefighters and Reserve Officers that informs you that you are eligible.
- The last day you are covered under any health plan (including COBRA coverage) through your loved one’s employer.
Questions about enrolling or deferring?
Please call the PEBB Program at 1-800-200-1004 (TRS: 711) or send us a secure message. You need to set up an account to protect your privacy and sensitive health information. Using our secure messaging system helps us ensure that your data is protected.
Supporting information
Qualified medical coverage is enrollment in other insurance, for example, through your spouse or state-registered domestic partner, or military affiliation. This may include:
- Enrollment as a dependent in a Washington State educational service district-sponsored, PEBB-sponsored, or SEBB-sponsored health plan
- Employer-based group medical
- Federal retiree medical plan such as a TRICARE plan or Federal Employees Health Benefits Program
- Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
- Medicare Part A and Part B and a Medicaid program that provides creditable coverage
- Enrollment in health benefit exchange coverage that is not Medicaid – for retirees not enrolled in Medicare Part A and Part B
Required forms
- Retiree Election Form (form A). Everyone must submit this form to enroll in or defer enrollment.
You may also need to submit any of the following forms, depending on your situation.
- Medicare Advantage Plan Election Form (form C). To enroll in a Medicare Advantage plan.
- Medicare Supplement Enrollment Form (form B). To enroll in Premera Blue Cross Medicare Supplement Plan G.
- Electronic Debit Service (EDS) Agreement. To pay your premiums through automatic bank account withdrawal.
- Declaration of Tax Status. To enroll a nonqualified tax dependent, like a state-registered domestic partner or their child.
- Certification of a Child with a Disability. To enroll a dependent child with a disability.
- Extended Dependent Certification. To enroll an extended (legal) dependent like a grandchild, niece, or nephew.
Supporting documents you may need
Note: If you are a survivor of a retiree who deferred PEBB retiree insurance coverage, you must also provide proof of continuous enrollment in qualifying medical coverage from the most recent open enrollment for which you were not enrolled in a PEBB medical plan before the retiree's death.
Related laws and rules
Contact
The PEBB Program
Phone: 1-800-200-1004
TRS: 711
Send us a secure message. You will need to set up an account to protect your privacy and sensitive health information. Using our secure messaging system helps us ensure that your data is protected.
