Forms & publications

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Premium surcharge attestation change form 2019

50-563-2019

This is the 2019 Premium Surcharge 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.

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Premium surcharge help sheet 2019

50-226-2019

This is the 2019 Premium Surcharge 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.

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Spousal plan calculator form 2019

50-027-2019

This is the 2019 Spousal plan calculator form. Use 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.

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Spousal plan calculator tool 2019 (xls)

This is the 2019 spousal plan calculator. 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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