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District of Columbia Temporary Continuation of Coverage Benefits Enrollment Form

Tuesday, December 3, 2013

If you were hired on or after October 1, 1987, you may have participated in the District healthcare program. If applicable, you may complete this form to enroll in the District's Temporary Continuation of Coverage (TCC) within certain periods of a qualifying event or recieving notice of eligibilty.  The premums for this coverage may be found by clicking on the second attachment below. Additional information about TCC qualifiying events can be found on pages 8 and 9 of the DPM issuance.  If you have questions, please contact the DCRB Member Services Center at (202) 343-3272. Please return the completed form to DCRB.