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
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.