Certificate of Coverage

YOUR BENEFIT PLAN WA State Health Care Authority PEBB Class 1 Retiree Term Life Plan: WA State Health Care Authority PEBB and WA State Health Care Authority SEBB employees enrolled in Basic Life Insurance who meet qualifications for enrollment in PEBB retiree insurance coverage on or after January 1, 2017; and Retirees who elected to move from the Policyholder’s $3,000 benefit plan to this Class 1 Retiree Term Life Plan during the 2016 open enrollment period Class 2 Legacy Retiree Term Life Plan: Retirees enrolled in the Policyholder’s $3,000 benefit plan prior to January 1, 2017 who did not move to the Policyholder’s new Class 1 Retiree Term Life Plan during the 2016 open enrollment period Retiree Term Life Insurance Certificate Date: January 1, 2024 Certificate Number 19