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

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.


Premium surcharges

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)

PEBB Retiree Insurance