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Premium surcharge attestation change form (PEBB) 2020
50-563This is the 2020 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.
FormPremium Surcharge Attestation Change form (PEBB) 2021
50-0563This 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.
FormPremium surcharge attestation change form (SEBB) 2020
20-0041This is the 2020 SEBB 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.
FormPremium Surcharge Attestation Change form (SEBB) 2021
20-0041This 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.
FormPremium surcharge attestation help sheet (PEBB) 2020
50-226This is the 2020 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.
FormPremium Surcharge Attestation Help Sheet (PEBB) 2021
50-0226This 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.
FormPremium surcharge attestation help sheet (SEBB) 2020
20-0040This is the 2020 SEBB 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.
FormPremium Surcharge Attestation Help Sheet (SEBB) 2021
20-0040This 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.
FormSpousal plan calculator form (PEBB) 2020
50-027This is the 2020 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.
FormSpousal Plan Calculator form (PEBB) 2021 (pdf)
50-0027This 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.
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