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 (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 Help Sheet (PEBB) 2021

50-0226

This is the 2021 Premium Surcharge Attestation Help Sheet. Use the information on this help sheet to attest on your enrollment form or the Premium Surcharge form whether the premium surcharges for tobacco use or spouse/state-registered domestic partner apply.

Form

Premium Surcharge Attestation Help Sheet (SEBB) 2021

20-0040

This is the 2021 SEBB 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.

Form

Spousal Plan Calculator form (PEBB) 2021 (pdf)

50-0027

This is the 2021 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions in the 2021 Premium Surcharge Attestation Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.

Form

Spousal Plan Calculator form (SEBB) 2021

20-0042

This is the 2021 SEBB Spousal plan calculator form. Use this form if you answered 'YES' to all the questions in the 2020 Premium Surcharge Attestation Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.

Form

Spousal Plan Calculator Tool (SEBB) 2021 (xls)

This is the 2021 SEBB Spousal plan calculator form. Use this form if you answered 'YES' to all the questions in the 2020 Premium Surcharge Attestation Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.

Form

Spousal Surcharge Calculator Tool (PEBB) 2021 (xls)

This is the 2021 Spousal plan calculator form. Use this form if you answered 'YES' to all the questions in the 2021 Premium Surcharge Attestation Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.

Form