In crisis?
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.
On this page
- Medical (with vision) and dental
- 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)
- Dependent certifications
- PEBB Continuation Coverage (COBRA and Unpaid Leave)
- PEBB Retiree Insurance
Want to have PEBB materials delivered to your organization?
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)
- Employee Authorization for Payroll Deduction for HSA 2022
- Beneficiary Designation
Find additional forms and documents on HealthEquity's website.
Life and accidental death and dismemberment (AD&D) insurance
- Certificate of Coverage (COC)
- MetLife's MyBenefits portal
- Employees can use MyBenefits 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 2022
- Notification of Enrollment Extension for Supplemental Life form 2022
- Privacy Notice
Long-term disability (LTD) insurance
- Plan Booklet 2022
- Enrollment/Change form 2022
- Evidence of Insurability
- Claim packet 2022
- Claim Information Sheet (employer groups only) 2022
- LTD error or discrepancy correction form 2022
Flexible Spending Arrangements (FSAs) and Dependent Care Assistance Program (DCAP)
For employees of state agencies and higher education institutions only.
- Midyear Enrollment form 2022
- FSA and DCAP Claim form 2022
- Change in Status Form
- Agency Transfer form
- FSA Termination form
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
