HCA’s lobby is now open for walk-in customer service. Learn about customer service options.

Forms

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

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Order materials

Medical (with vision) and dental

  • Employee Enrollment/Change form 2022
  • Employee Enrollment/Change form - medical only 2022
  • Employee Enrollment Guide 2022

Premium surcharges

  • Premium Surcharge Change form 2022
  • Premium Surcharge Help Sheet 2022
  • Spousal Plan Calculator (print version) 2022
  • Spousal Plan Calculator tool (interactive tool) 2022

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

    Dependent certifications

    • Extended Dependent Certification 2022
    • Certification of a Child with a Disability 2022
    • Declaration of Tax Status 2022

    PEBB Continuation Coverage (COBRA and Unpaid Leave)

    • Continuation Coverage Election Notice 2022
    • Initial notice of COBRA and Continuation Coverage rights 2022
    • Continuation Coverage (COBRA) Election/Change form 2022
    • Continuation Coverage (Unpaid Leave) Election/Change form 2022

    PEBB Retiree Insurance