Spousal Plan Calculator form (PEBB) 2022 (pdf)

50-0027

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.

Form

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.

Form