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Enrollment Forms

If a form has (Complete Online) next to it, you can do this online by going to Manage My Benefits.
It's easier, faster and leads to fewer mistakes than printing a form and sending it to PEIA.  Full instructions can be found here.

***If you have previously had PEIA as your insurance carrier, you are unable to use Manage My Benefits to log in and enroll. 
Please see your HR department to fill out paper enrollment forms.

Preferred Provider Benefit (PPB) Plans
Comprehensive Care Program Enrollment Form
Change-in-Status Form (Complete Online)

Disabled Dependent Eligibility Application
Health Benefits Enrollment Form (Complete Online)

Retiree Basic Life and Health Enrollment Form​
Surviving Dependents Health Benefits Enrollment Form
Termination Form  (Complete Online)

Life Insurance
Basic Life Insurance Enrollment Form (Complete Online)
Basic and/or Optional Life Insurance Change of Beneficiary Form​ 
Optional Life Insurance and Dependent Life Insurance Enrollment Form (Complete Online)
Retired Employee's Optional and Dependent Life Insurance Enrollment Form