1
1
HCA 50-0136 (10/23)
2024 PEBB Continuation Coverage
(COBRA) Election/Change
 
 
 hca.wa.gov/gender-x.

PEBB Continuation Coverage Election Notice
no later




PEBB Continuation Coverage (COBRA) Election/Change



hca.wa.gov/pebb-continuationForms & publications

Remember to read and sign Section 7.



 
1 Subscriber
  
1
 

2
 
  
Phone number Alternate phone number
*50-0136*
2
2



 



 
You must report your new address to the PEBB Program aer you move. You can report
it by using this form, sending a written request by mail or secure message (see "Form return" on page 13), or
calling 1-800-200-1004 (TRS: 711).
  











You may elect to continue coverage you were
enrolled in on the day your PEBB health plan
coverage ended. If you have PEBB life insurance
you wish to port or convert, call MetLife at
1-866-548-7139.
If you are enrolled in a Medical Flexible Spending
Arrangement (FSA) or a Limited Purpose FSA
and would like to continue it, call Navia Benet
Solutions at 1-800-669-3539. Navia must receive
your request  from the date
your PEBB health plan coverage ended, or from the
postmark date on the Navia COBRA election notice
sent to you, whichever is later.
If you terminate all coverage, you will not be eligible to enroll again in PEBB Continuation Coverage unless
you regain eligibility.
 

3
3

  

  

  




  

  







Premium surcharges do not apply to subscribers who are enrolled in Medicare Part A and Part B.

















PEBB Premium Surcharge Attestation Change Form


 

4
4
2 Spouseorstate-registereddomesticpartner(SRDP)




hca.wa.gov/pebb-continuation





If enrolling an SRDP, attach a PEBB Declaration of Tax Status to indicate whether they qualify as a dependent for
tax purposes.
  
1
 

2
  X
  


S
 
1

2

 hca.wa.gov/gender-x

 

 
If removing a spouse due to divorce, attach a
copy of the divorce decree. If removing an SRDP
due to dissolution, attach a copy of the dissolution
of state-registered domestic partnership.

  

 

5
5

  

  

  




  

  







Premium surcharges do not apply to subscribers who are not enrolled in Medicare Part A and Part B.






PEBB Premium Surcharge Attestation Change Form


 

6
6





1.  1
2. 

 
 
  not 


6. 


1. 
 
 
2. 

If you check Yes below or leave this section blank, you will be charged the $50 premium surcharge.


PEBB Spousal Plan Calculator
PEBB Spousal Plan Calculator
PEBB Spousal Plan
Calculator

hca.wa.gov/pebb-continuationSurcharges
PEBB Premium Surcharge Attestation Change Form
 

7
3 




hca.wa.gov/pebb-continuation


PEBB Declaration of Tax Statu








  
1
 
2
 
  


 

 

 

 


1

2


If adding more dependents, copy
pages 7 and 8 and attach to this form.
 

8

  

  

  




  

  












PEBB Premium Surcharge Attestation Change Form


 

9
4 

 

 












 


   














 

10
















PEBB
PEBB Declaration of Tax Status


PEBB Declaration of Tax Status












 

11
5 


1,2



5

3

1


6

5





6


 



5

5







 




 




 





 


 


 



 



 







 

12
6 










 

13
7 
PEBB Continuation Coverage
Election Notice
























































PEBB Continuation Coverage
(COBRA) Election/Change


 
 
 






















 


8



































































































 

15





































































































 

16

Do not send forms to the addresses below. This information is only for your reference.



















































 
