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District of Columbia Temporary Continuation of Coverage Benefits Enrollment Form

Thursday, September 15, 2022

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 receiving notice of eligibility.  The premiums for this coverage may be found by clicking on the second attachment below. Additional information about TCC qualifying events can be found on pages 8 and 9 of the DPM issuance

You can send the completed form and any required attachments by fax to (202) 566 -5001 or by mailing your documents to:

DC Retirement Board
Member Services Center
900 7th Street, NW, Second Floor
Washington, DC 20001

If you have further questions, please contact the DCRB Member Services Center by clicking on the Ask Member Services link, or by phone at (202) 343-3272 Monday – Friday from 8:30 am to 5:00 pm.