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Forms

When printing forms to share with employees, also provide the PEBB nondiscrimination statement and language access notice.

Employee medical/dental

  • Employee Enrollment/Change form 2021
  • Employee Enrollment/Change form - medical only 2021
  • Employee Enrollment Guide 2021

Tobacco use and spousal premium surcharges

  • Premium Surcharge Change form 2021
  • Premium Surcharge Help Sheet 2021
  • Spousal Plan Calculator (print version) 2021
  • Spousal Plan Calculator tool (excel version) 2021

Life insurance

Long-term disability (LTD) insurance

Health Savings Account (HSA)

Medical Flexible Spending Arrangement (FSA) and Dependent Care Assistance Program (DCAP)

Dependent certifications

  • Declaration of Tax Status 2021
  • Extended Dependent Certification 2021
  • Certification of a Child with a Disability 2021

Miscellaneous