Forms and publications
When printing forms to share with employees, also provide the PEBB nondiscrimination statement and language access notice.
On this page
Want to have PEBB materials delivered to your organization?
- Employee Enrollment Guide 2022 | 2023
- Employee Enrollment/Change form 2022 | 2023
- Employee Enrollment/Change form - medical only 2022 | 2023
- Dependent verification requirements
- Declaration of Tax Status form 2022 | 2023
- Extended Dependent Certification form 2022 | 2023
- Certification of a Child with a Disability form 2022 | 2023
- 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
Find additional forms and documents on HealthEquity's website.
- 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 2022 | 2023
- Notification of Enrollment Extension for Supplemental Life form 2022
- Privacy Notice
- LTD Administration Manual
- Plan Booklet 2022 | 2023
- Enrollment/Change form
- Evidence of Insurability form
- Claim packet
- Claim Information Sheet (employer groups only)
- LTD error or discrepancy correction form 2022
For employees of state agencies and higher education institutions only.
- 2023 OE enrollment form
- Midyear Enrollment form 2022
- FSA and DCAP Claim form 2022
- Change in Status form
- Agency Transfer form
- FSA Termination form
Find additional forms and documents on Navia's website.
- Continuation Coverage Election Notice 2022
- Initial notice of COBRA and Continuation Coverage rights 2022