Premium Surcharge Attestation Change form (SEBB) 2021

20-0041

This is the 2021 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.

Form

Premium Surcharge Attestation Change form (SEBB) 2022

20-0041

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.

Form