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?

Employee enrollment guide and forms

  • Employee Enrollment Guide 2022 | 2023
  • Employee Enrollment/Change form 2022 | 2023
  • Employee Enrollment/Change form - medical only 2022 | 2023

The forms provided above are for employee and dependent enrollment in PEBB medical (with vision) and dental. Additional enrollment forms and resources can be found in the sections below.

Dependents

Premium surcharges

  • Premium Surcharge Help Sheet 2022 | 2023
  • Premium Surcharge Change form 2022 | 2023
  • Spousal Plan Calculator (print version) 2022 | 2023
  • Spousal Plan Calculator tool (interactive tool) 2022 | 2023

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