Forms & publications

Premium Surcharge Attestation Change form (SEBB) 2022

This is the 2022 SEBB Premium Surcharge Attestation Change form. Use this form to report a change that affects your surcharge for tobacco use and spouse or state-registered domestic partner coverage.

Premium Surcharge Attestation Change form (SEBB) 2023

This is the 2023 SEBB 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.