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Forms & publications
Can't find what you need? Visit UMP Forms and publications for more documents.
Premium surcharge change form 2018
50-563-2018Use this form to report a change that affects your surcharge for tobacco use and/or spouse or state-registered domestic partner coverage.
FormPremium surcharge change form 2019
50-563-2019Use this form to report a change that affects your surcharge for tobacco use and/or spouse or registered domestic partner coverage.
FormPremium surcharge help sheet 2018
50-226-2018Use the information on this help sheet to attest on your enrollment form or the Premium Surcharge change form whether the premium surcharges apply.
FormPremium surcharge help sheet 2019
50-226-2019Use the information on this help sheet to attest on your enrollment form or the Premium Surcharge form whether the premium surcharges apply.
FormSpousal plan calculator form 2018
50-027-2018Use this noninteractive form if you answered 'YES' to all the questions in the 2018 Premium Surcharge Help Sheet and are wanting to enroll a spouse or state-registered domestic partner on your PEBB medical.
FormSpousal plan calculator form 2019
50-027-2019Use this form if you answered 'YES' to all the questions in the 2019 Premium Surcharge Help Sheet and are wanting to enroll a spouse or state-registered domestic partner.
FormSpousal plan calculator tool 2018 (xls)
Use this interactive calculator tool to determine if the spousal premium surcharge applies to you if you answered 'YES' to all the questions in the Premium Surcharge Help Sheet and are wanting to enroll a spouse or state-registered domestic partner on your PEBB medical.
FormSpousal plan calculator tool 2019 (xls)
Use this interactive calculator tool to determine if the spousal premium surcharge applies to you if you answered 'YES' to all the questions in the Premium Surcharge Help Sheet and are wanting to enroll a spouse or state-registered domestic partner on your PEBB medical.
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