Forms & publications

Premium Surcharge Attestation Help Sheet (PEBB) 2022

This is the 2022 PEBB Premium Surcharge Attestation Help Sheet. 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 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.

Spousal Plan Calculator (PEBB) 2023 (pdf)

This is the 2023 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions in the 2023 Premium Surcharge Attestation Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.

Spousal Plan Calculator form (PEBB) 2022 (pdf)

This is the 2022 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions in the 2022 Premium Surcharge Attestation Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.

Spousal Plan Calculator Tool (PEBB) 2023 (xls)

This is the 2023 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions in the 2023 Premium Surcharge Attestation Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.

Spousal Surcharge Calculator Tool (PEBB) 2022 (xls)

This is the 2022 Spousal plan calculator tool. Use this form if you answered 'YES' to all the questions in the 2022 Premium Surcharge Attestation Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.