Forms & publications

Premium Surcharge Attestation Change form (PEBB) 2022

This is the 2022 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

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.