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PEBB Benefit Eligibility Tools and Worksheets
PEBB provides the following method to determine eligibility for the employer contribution
toward benefits for employees of state agencies. The method facilitates decisions compliant
with RCW and WAC, provides required notice and information to employees, confirms receipt of
that notice and information, and provides guidance and suggestions for the employer and the
employee.
| Step 1 |
Choose the Tool (e.g., New Hire) below which describes the situation of the employee
for whom you are determining eligibility for the employer contribution. The "Did you mean?" column is provided to guide
you to other Worksheets which may be appropriate for similar situations. |
| Step 2 |
Click on the title of the specific Worksheet which describes that employee or employee
situation. The Worksheet will be displayed. |
| Step 3 |
Either print the Worksheet and fill it out or fill it out electronically and print it
or save it to your chosen location. When finished, either close the Worksheet
(which will clear all fields). |
| Step 4 |
As noted on each Worksheet, have the employee sign it and give them a copy. If the
employee is not with you to sign it, send them an unsigned copy and ask them to return a
signed copy or send an email confirming receipt of a copy. |
| Step 5 |
File the Worksheet as a hard copy or electronically for your use or review by HCA/PEBB. |
 Guide to Eligibility Worksheets (131.6 KB)
Tool A: New Hire
| Worksheet |
Did you mean? |
| A-1 Employees (Salaried and Hourly) |
- New transfer from another state agency/higher ed, use A-5
- Returning from layoff with gap in eligibility 24 months or less, use D-2
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| A-2 Employees (Seasonal - 3 to 11 months this season, work that recurs) |
- New transfer from another state agency/higher ed, use A-5
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| A-3 Faculty (First faculty work at your institution) |
- Returning from layoff with gap in eligibility 24 months or less, use D-2
- Returning after a period without eligibility, use D-3
- Worked previous Quarter/Semester, use B-2
- Changes in work load or duration, use B-2 or B-3
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| A-4 Legislators, Judges, or Newly Appointed Officials |
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| A-5 Transferring to/from Another State Agency/HE (Inbound or Outbound with no break in service or coverage) |
- Break in coverage, use A-1
- Return from layoff, use D-2
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Tool B: Existing Employee/Faculty Review of Benefit Eligibility
Tool C: Eligible Employees Leaving Work - Temporarily or Permanently
Tool D: Employees Returning to Work
Tool E: Dependents
Tool F: None of the above appears relevant
Contact PEBB Outreach & Training via the Info Center or 1-800-700-1555
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