Premium Surcharge Attestation Change form (PEBB) 2021

50-0563

This is the 2021 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.

Form

Premium Surcharge Attestation Change form (PEBB) 2022

50-0563

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

Form