Certificate of Coverage

YOUR BENEFIT PLAN WA State Health Care Authority PEBB All Actively at Work employees of an Employing Agency, except for employees of an Employer Group that do not contract with the Policyholder for the insurance benefits described in this certificate Totally Disabled Patrolmen, Disability Leave Patrolmen and Disability Status Patrolmen deemed disabled in the line of duty by the Chief of Washington State Patrol (WSP) Basic Life Insurance Supplemental Life Insurance Dependent Life Insurance Basic Accidental Death and Dismemberment Insurance Supplemental Accidental Death and Dismemberment Insurance Dependent Accidental Death and Dismemberment Insurance Certificate Date: January 1, 2024 Certificate Number 18