Forms and publications

When printing forms to share with employees, also provide the PEBB nondiscrimination statement and language access notice.

Want to have PEBB materials delivered to your organization?

Medical (with vision) and dental

  • Employee Enrollment/Change form 2022
  • Employee Enrollment/Change form - medical only 2022
  • Employee Enrollment Guide 2022

Dependents

Premium surcharges

  • Premium Surcharge Help Sheet 2022
  • Premium Surcharge Change form 2022
  • Spousal Plan Calculator (print version) 2022
  • Spousal Plan Calculator tool (interactive tool) 2022

Health Savings Account (HSA)

Find additional forms and documents on HealthEquity's website.

Life and accidental death and dismemberment (AD&D) insurance

Long-term disability (LTD) insurance

Flexible Spending Arrangements (FSAs) and Dependent Care Assistance Program (DCAP)

For employees of state agencies and higher education institutions only.

Find additional forms and documents on Navia's website.

    PEBB Continuation Coverage (COBRA and Unpaid Leave)

    • Continuation Coverage Election Notice 2022
    • Initial notice of COBRA and Continuation Coverage rights 2022

    PEBB Retiree Insurance

    • Retiree Enrollment Guide 2022