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List eligible family members you wish to cover or remove from coverage. This form replaces all Retiree Coverage Election Forms previously submitted. If deferring PEBB retiree coverage only, complete sections 1, 7, 8 (if applicable), and 9. If adding a dependent with a disability age 26 or older, select a medical plan on this form and complete and submit the PEBB Certification of Dependent with a Disability form as instructed on the form. Forms are available at www.hca.wa.gov/pebb or.

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