Forms and publications
When printing forms to share with employees, also provide the PEBB nondiscrimination statement and language access notice.
On this page
- Employee enrollment guide and forms
- Dependents
- Premium surcharges
- Health Savings Account (HSA)
- Life and accidental death and dismemberment (AD&D) insurance
- Long-term disability (LTD) insurance
- Flexible Spending Arrangements (FSAs) and Dependent Care Assistance Program (DCAP)
- PEBB Continuation Coverage (COBRA and Unpaid Leave)
- PEBB Retiree Insurance
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Employee enrollment guide and forms
- Employee Enrollment Guide
- Employee Enrollment/Change form
- Employee Enrollment/Change form - medical only
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
- Find a list of valid dependent verification documents on the Dependents page and in PEBB Policy 31-1
- Dependent enrollment and verification instructions
- Declaration of Tax Status form
- Extended Dependent Certification form
- Certification of a Child with a Disability form
Premium surcharges
- Premium Surcharge Help Sheet
- Premium Surcharge Change form
- Spousal Plan Calculator (print version)
- Spousal Plan Calculator tool (interactive tool)
Health Savings Account (HSA)
Find additional forms and documents on HealthEquity's website.
Life and accidental death and dismemberment (AD&D) insurance
- Life and AD&D Administration Manual
- Certificate of Coverage (COC)
- MetLife's MyBenefits portal
- Employees can use the MyBenefits portal to add/update beneficiaries and elect/change supplemental coverages.
- MetLife Enrollment/Change form
- Beneficiary Designation form
- Cancellation of Supplemental Life and AD&D Insurance form
- Notification of Enrollment Extension form for supplemental life
- Privacy Notice
Long-term disability (LTD) insurance
- LTD Administration Manual
- Plan Booklet
- Enrollment/Change form
- Evidence of Insurability form
- Claim packet
- Claim Information Sheet (employer groups only)
- LTD error or discrepancy correction form
Flexible Spending Arrangements (FSAs) and Dependent Care Assistance Program (DCAP)
For employees of state agencies and higher education institutions only.
- Midyear Enrollment form
- FSA and DCAP Claim form
- Change in Status form
- Agency Transfer form
- FSA Termination form
Find additional forms and documents on Navia's website.