Forms and publications

Below you will find manuals, user guides, and resources related to the Benefits 24/7 online enrollment system, accounting, correcting employer errors, appeals, and HCA Support. Employee enrollment resources, such as guides and forms, certification forms for dependents, and many other resources are also available to download.

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

Benefits 24/7

Benefits 24/7 manuals and resources

The following resources are for benefits administrators (BAs).

• Benefits 24/7
• Benefits 24/7 manuals
  • Chapter 1: Introduction to Benefits 24/7
  • Chapter 2: Managing Benefits 24/7
  • Chapter 3: Managing employee accounts
• Benefits 24/7 FAQ
• First working day of the month/effective date of coverage table (2024) (2025)
• Lower limit calendar (2024) (2025)
  • Policy 19-1A: Termination due to loss of eligibility or enrollment error (2024) (2025)

Benefits 24/7 training environment:

• Benefits 24/7 training environment
• Benefits 24/7 training environment login user guide

For employer groups who do not enter enrollment in the insurance system:

• Insurance Eligibility Adjustment Form

Learn more on the Administering PEBB in Benefits 24/7 webpage.

Accounting

Accounting manuals and resources

The accounting manuals contain the current year's invoicing dates along with other accounting-related guidance. The accounting manual for state agencies also contains the state share cutoff dates.

• Accounting manuals:
  • State agencies
  • Institutions of higher education
  • PEBB participating employer groups
• Billing/invoicing dates (and state share dates for state agencies) can be found in the accounting manual for your employer type.
• State payroll reconciliation resources(PEBB accounting/OFM/HRMS)
• Lower limit calendar (2024) (2025)

These resources can also be found on the Accounting webpage.

Correcting PEBB employer errors

Correction resources for state agencies and institutions of higher education

• Correcting employer errors webpage
• Failure to enroll accurately
• Failure to enroll in default coverage
• Failure to timely notify newly eligible employee

Correction resources for employer groups

• Correcting employer group errors webpage

Appeals

Appeals resources for state agencies and institutions of higher education

• PEBB Appeals process map
• Employee Request for Review/Notice of Appeal form
• Authorization for Release of Information

Learn more on the Appeals process webpage.

Appeals resources for employer groups

• Appeals process for employer groups webpage

HCA Support

HCA Support is a secure, web-based correspondence program that allows you to send documents and communicate directly with O&T, PEBB Accounting, and other departments within the PEBB Program by using the designated tile named, "Benefits administrator inquiry".

HCA Support resources

It's important that BAs use the designated tile named, "Benefits administrator inquiry". Using the "General Support" tile will lead to a delayed response, as your inquiry will be initially routed to units at HCA that are outside of O&T.

• HCA Support
  • HCA Support user guide

Employees and dependents

Enrollment guide, forms, and resources

Employees are encouraged to complete enrollment online using Benefits 24/7. However, the forms provided below can also be used for employee and dependent enrollment.

• Employee Enrollment Guide (2024) (2025)
• Employee Enrollment/Change form (2024) (2025)
• Employee Enrollment/Change form - medical only (2024) (2025)
• LTD Enrollment/Change form

Employees may use the following forms to complete their enrollment in supplemental life and supplemental accidental death and dismemberment (AD&D) insurance and to elect participation in a flexible spending arrangement (FSA) or the Dependent Care Assistance Program (DCAP). Enrollment in these benefits cannot be completed using Benefits 24/7.

• MetLife Enrollment/Change form (for electing supplemental life and AD&D insurance and adding beneficiaries)
  • MetLife Beneficiary Designation form (for adding or updating beneficiaries only)
• FSA and DCAP Midyear Enrollment form (for eligible employees of a state agency or institution of higher education only) (2024) (2025)

Learn more on the Newly eligible employees webpage.

Dependent forms and resources

• Certification of a Child with a Disability form
• Extended Dependent Certification form
• Declaration of Tax Status form (2024) (2025)
• PEBB Policy 31-1: Dependent verification
• PEBB Policy 33-1: Additional verification requirements for partners of a legal union
• PEBB Policy 36-1: Certifying eligibility for a dependent child with a disability who is age 26 or older (2024) (2025)
• PEBB Policy 37-1: Certifying eligibility for an extended dependent child (2024) (2025)

Learn more on the Dependents webpage.

Premium surcharges

• Premium Surcharge Change form (2024) (2025)
  • Help Sheet information can be found in the Premium Surcharge Attestation Change form.
• Spousal Plan Calculator (print version) (2024) (2025)
• Spousal Plan Calculator tool (interactive tool) (2024) (2025)

Learn more on the Premium surcharges webpage.

Life and accidental death and dismemberment (AD&D) insurance

Life and AD&D forms and resources

• Life and AD&D Administration Manual
• Life insurance Certificate of Coverage (COC)
• AD&D insurance Certificate of Coverage (COC)
• MetLife Advantages
  • Empathy services for beneficiaries
• Employees can use MetLife's MyBenefits portal to add/update beneficiaries and elect/change supplemental coverages or they can use the forms provided below.
  • MetLife Enrollment/Change form
  • Beneficiary Designation form
  • Cancellation of Supplemental Life and AD&D Insurance form
• Notification of Enrollment Extension form for supplemental life
• Privacy Notice

Learn more on the Life and AD&D webpage.

Long-term disability (LTD) insurance

LTD forms and resources

• LTD Administration Manual
• Plan Booklet
• Enrollment/Change form
• Evidence of Insurability form
• Claim Packet
  • Employer's Statement (LTD claims)
• Claim Information Sheet (employer groups only)
• LTD error or discrepancy correction form

Learn more on the LTD webpage.

Flexible Spending Arrangements (FSAs) and Dependent Care Assistance Program (DCAP)

FSA and DCAP forms and resources

The FSAs and DCAP offered through the PEBB Program are available to eligible employees of state agencies and higher education institutions.

• Midyear Enrollment form (2024) (2025)
• FSA and DCAP Claim form (2024) (2025)
• Change in Status form (2024) (2025)
• Agency Transfer form
• FSA Termination form
• Find additional forms and documents on Navia's website.

Learn more on the FSA and DCAP webpage.

Additional forms and resources

Apple Health (Medicaid)

• CHIP and PEBB/SEBB coverage options

  • Annual CHIPRA Notice template

Dual enrollment

• Dual enrollment Q&A for BAs

Learn more on the Newly eligible employees webpage.

Health Savings Account (HSA)

• Employee Authorization for Payroll Deduction for HSA (2024) (2025)
• Beneficiary Designation form
• Find additional forms and documents on HealthEquity's website.

Learn more on the Medical plans with health savings accounts webpage.

Premium payments

• Premium Payment Plan Election/Change form
• Electronic Debit Service (EDS) Agreement

Learn more on the Paying for benefits and the Premium payment plan (IRC Section 125) webpages.

PEBB Continuation Coverage

COBRA and Unpaid Leave resources

• Initial notice of COBRA and Continuation Coverage rights (2024) (2025)
• Continuation Coverage Election Notice (2024) (2025)

Learn more on the COBRA and Unpaid Leave webpages.

PEBB retiree insurance

PEBB retiree insurance resources

• Retiree Enrollment Guide (2024) (2025)
• PEBB retiree health insurance checklist

Learn more on the Retiring and PEBB Retiree Insurance webpage.