Employees and retirees must complete and submit this form with their enrollment form when enrolling an individual on their PEBB Program coverage who does not qualify as their dependent for federal tax purposes.
Electronic Debit Service (EDS) is only available to retirees and continuation coverage subscribers. Electronic service allows PEBB subscribers to have monthly payments automatically taken from a checking or savings account.
Premium Surcharge Attestation Help Sheet (PEBB) 2023
This is the 2023 PEBB Premium Surcharge Attestation Change form. Use this form to report a change that affects your surcharge for tobacco use and/or spouse or state-registered domestic partner coverage.