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Retiree coverage election form (form A) 2020

Retiree coverage election form (form A) 2020-2025

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The document is a 2020 PEBB Employee Enrollment/Change form that outlines the process for employees to enroll in or make changes to their health insurance coverage under the Public Employees Benefits Board (PEBB) program. It includes sections for subscriber information, dependent information, medical and dental plan selections, and details about premium surcharges related to tobacco use and spousal coverage. The form emphasizes the importance of providing accurate information and documentation to ensure timely enrollment and coverage.

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