Forms & publications

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PEBB Premium surcharge attestation help sheet 2019

50-226-2019

This is the 2019 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 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.

Form

SEBB premium surcharge attestation change form 2020

20-0041

This 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.

Form

SEBB premium surcharge attestation help sheet 2020

20-0040

This 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.

Form

SEBB spousal plan calculator form 2020

20-0042

This is the 2020 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

SEBB spousal plan calculator tool 2020 (xls)

This is the 2020 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 SEBB Premium Surcharge Attestation Help Sheet and are wanting to enroll a spouse or state-registered domestic partner on your SEBB medical.

Form

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.

Form

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.

Form