Skip to main content Homepage

PEBB and Other Carrier Forms

1095 Proof of Coverage for the 2021 tax year

  • All full-time employees in 2021 who enrolled or opted out of a PEBB plan should receive a 1095-C.  
  • Part-time employees in 2021 who enrolled in Providence or Moda should also receive a 1095-C. 
  • Any employee enrolled in a Kaiser plan should receive a 1095-B from Kaiser. 
When will 1095-C's be sent?
The IRS granted an extension of due date for furnishing statements. The due date for furnishing Form 1095-C to individuals is extended from January 31, 2022, to March 2, 2022. See Proposed Regulations section 301.6056-1(g) and Extensions of time to furnish statements to recipients.

Do 1095-Cs need to be sent with my tax returns?
No. These forms should not be attached to the return or sent to the IRS. The issuers of the forms (State of Oregon) are required to send the information to the IRS separately. You should keep the forms for your records, with your other important tax documents. For more information:

Not sure which form to fill out or have other benefit related questions?  
Contact Member Services at (503) 373-1102 or

We are experiencing a higher than normal call volume. Please leave a message for Member Services and they will return your call within 24-48 hours, or you may choose to email your question instead. 

We want to be supportive! For the best experience, please do not view this page in Internet Explorer.

Filling out forms:

  1. Use the Searching Forms instructions, if needed, to help find the form you need.
  2. Open the form by clicking the Title.
  3. Download the form to the Documents folder on your computer before filling it out.
  4. Open the form from your computer, and be sure to fill in all Required Fields
  5. Save your PDF before sharing it!
  6. The last page of each form has information about where to send it.

Searching Forms

  1. Enter one word, such as, 'new,' 'change,' 'divorce,' 'affidavit, enrollment, fsa, etc.


Other search options:
  1. Click desired column Header (example: category, url, descripton, form number) to sort OR;
  2. Use Sort dropdown and choose a different column to sort A-Z.
  1. Click Filter dropdown to choose filter options or;
Viewing More Pages:
  1. Click Next at the bottom of the forms list, if needed OR; 
  2. Use the 'Per Page' dropdown located in the lower right hand corner to adjust how many forms you see on one page.