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Spousal plan questionnaire 2021

 
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Use this questionnaire to determine if you need to pay a premium surcharge for your spouse or state-registered domestic partner.

If you don’t have a spouse or state-registered domestic partner on your PEBB medical plan, you don’t need to complete this questionnaire – this surcharge doesn’t apply to you.

If you have a spouse or state-registered domestic partner enrolled on your 2021 PEBB medical plan, you must:

  1. Answer YES to question 1 (the only option)
  2. YES or NO to questions 2- 6

    AND
  3. Check the corresponding boxes on your 2021 enrollment/change form or 2021 Premium Surcharge Attestation Change form and return to your payroll or benefits office (employees) or the PEBB Program (all other subscribers).