the election period ends as described above. For more information, see “Options for continuing PEBB dental coverage” and the PEBB Continuation Coverage Election Notice. Retiree and survivor enrollment An eligible retiree, a survivor, or their dependent can enroll in only one PEBB dental plan, even if eligibility criteria is met under two or more subscribers. An eligible retiring employee or a retiring school employee must submit a PEBB Retiree Election Form (form A) along with any other required forms and supporting documents to the PEBB Program. They must be received no later than 60 days after the employee’s or the school employee’s employer-paid coverage, COBRA coverage, or continuation coverage ends. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends. An eligible elected or full-time appointed official must submit a PEBB Retiree Election Form (form A) along with any other required forms and supporting documents to the PEBB Program. They must be received no later than 60 days after the official leaves public office. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends. An eligible survivor of a retiree must submit a PEBB Retiree Election Form (form A) along with any other required forms and supporting documents to the PEBB Program. They must be received no later than 60 days after the death of the retiree. An eligible survivor of an employee or school employee must submit a PEBB Retiree Election Form (form A) along with any other required forms and supporting documents to the PEBB Program. They must be received no later than 60 days after the later of the date of the employee’s or the school employee’s death, or the date the survivor’s PEBB insurance coverage, educational service district coverage, or SEBB insurance coverage ends. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends. An eligible employee or school employee determined to be retroactively eligible for disability retirement must submit a PEBB Retiree Election Form (form A) along with any other required forms, supporting documents, and their formal determination letter to the PEBB Program. They must be received no later than 60 days after the date on the determination letter. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends. An eligible survivor of an emergency service personnel killed in the line of duty must submit a PEBB Retiree Election Form (form A) along with any other required forms and supporting documents to the PEBB Program. They must be received no later than 180 days after the later of: • The date on the letter from the Department of Retirement Systems or the Board for Volunteer Firefighters and Reserve Officers that informs the survivor that they are determined to be an eligible survivor; • The date of the emergency service worker’s death; or • The last day the survivor was covered under any health plan through the emergency service worker’s employer or COBRA coverage from the emergency service worker’s employer. A retiree or a survivor who deferred enrollment and is enrolling in a PEBB retiree health plan, must submit a PEBB Retiree Election Form (form A) along with any other required forms, supporting documents, and evidence of continuous enrollment to the PEBB Program. They must be received no later than 60 days after a loss of other qualifying coverage. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends. Dependent enrollment If a retiree or a survivor chooses to enroll in a dental plan under PEBB retiree insurance coverage, any dependents enrolled on the retiree or survivor’s account will also be enrolled in dental coverage. If a subscriber chooses to enroll an eligible dependent, the subscriber must include the dependent’s information on the applicable enrollment form and provide the required document(s) as proof of the dependent’s eligibility. The dependent will not be enrolled in PEBB health plan coverage if the PEBB Program or the employing agency is unable to verify their eligibility within the PEBB Program enrollment timelines. 2024-01-03000-BB 21 LG PPOL 20240101