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

• MetLife Certificate of Coverage (COC)
• MetLife Enrollment/Change form 2021
• Beneficiary Designation form
• MetLife Privacy Notice
• MetLife MIB PreNotice
• MetLife Cancellation form 2021
• MetLife Notification of Enrollment Extension form

Long-term disability (LTD) insurance

• LTD Certificate of Coverage (COC) 2021
• LTD Enrollment/Change form
• LTD Evidence of Insurability
• Employee's Statement
• Employer's Statement
• LTD Claim Information Sheet (for use by employer groups only)
• LTD Error Correction Form and Instructions

Health Savings Account (HSA)

• Employee Authorization for Payroll Deduction for HSA 2021
• Beneficiary Designation

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

• All Medical FSA/DCAP forms

Dependent certifications

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

Miscellaneous

• Premium Payment Plan Election/Change 2021
• Authorization for Release of Information
• Electronic Debit Service Agreement 2021
• Insurance Eligibility Adjustment form
• Employee Request for Review/Notice of Appeal