Form preview

Get the free PEBB Premium Surcharge Attestation Change Form 2020

Get Form
Clear Form2020 WEBB Premium Surcharge Attestation Change Forms this form to report a change that affects your premium surcharge for tobacco use and/or spouse or state registered domestic partner (as
We are not affiliated with any brand or entity on this form
4,4
98,753 Reviews
4,5
11,210 Reviews
4,6
715 Reviews
4,6
789 Reviews

Get, Create, Make and Sign pebb premium surcharge attestation

Edit
Edit your pebb premium surcharge attestation form online
Type text, complete fillable fields, insert images, highlight or blackout data for discretion, add comments, and more.
Add
Add your legally-binding signature
Draw or type your signature, upload a signature image, or capture it with your digital camera.
Share
Share your form instantly
Email, fax, or share your pebb premium surcharge attestation form via URL. You can also download, print, or export forms to your preferred cloud storage service.

How to edit pebb premium surcharge attestation online

9.5
Ease of Setup
pdfFiller User Ratings on G2
9.0
Ease of Use
pdfFiller User Ratings on G2
In order to make advantage of the professional PDF editor, follow these steps below:
1
Register the account. Begin by clicking Start Free Trial and create a profile if you are a new user.
2
Upload a document. Select Add New on your Dashboard and transfer a file into the system in one of the following ways: by uploading it from your device or importing from the cloud, web, or internal mail. Then, click Start editing.
3
Edit pebb premium surcharge attestation. Rearrange and rotate pages, insert new and alter existing texts, add new objects, and take advantage of other helpful tools. Click Done to apply changes and return to your Dashboard. Go to the Documents tab to access merging, splitting, locking, or unlocking functions.
4
Get your file. Select the name of your file in the docs list and choose your preferred exporting method. You can download it as a PDF, save it in another format, send it by email, or transfer it to the cloud.
With pdfFiller, dealing with documents is always straightforward.

Uncompromising security for your PDF editing and eSignature needs

Your private information is safe with pdfFiller. We employ end-to-end encryption, secure cloud storage, and advanced access control to protect your documents and maintain regulatory compliance.
Learn more about security & compliance
GDPR
AICPA SOC 2
PCI
HIPAA
CCPA
FDA

How to fill out pebb premium surcharge attestation

Illustration

How to fill out pebb premium surcharge attestation

01
To fill out the PEBB premium surcharge attestation, follow these steps: 1. Obtain the PEBB premium surcharge attestation form from your employer or health insurance provider.
02
Read the form carefully and familiarize yourself with the requirements and instructions.
03
Provide your personal information, including your name, address, and contact details, as required.
04
Indicate your current health insurance coverage and the health insurance coverage of your eligible dependents, if applicable.
05
Determine if you or any of your eligible dependents meet the tobacco use criteria and mark the appropriate box accordingly.
06
If you or any of your eligible dependents meet the tobacco use criteria, sign the attestation to acknowledge the premium surcharge.
07
Submit the completed PEBB premium surcharge attestation form to your employer or health insurance provider by the designated deadline.
08
Keep a copy of the completed form for your records.

Who needs pebb premium surcharge attestation?

01
Anyone who is enrolled in the Public Employees Benefit Board (PEBB) health insurance program and has eligible dependents needs the PEBB premium surcharge attestation. This form helps to determine if the employee or their eligible dependents meet the tobacco use criteria as part of the premium surcharge assessment. It ensures that the correct premium amount is charged based on the individual's tobacco use status.
Fill form : Try Risk Free
Users Most Likely To Recommend - Summer 2025
Grid Leader in Small-Business - Summer 2025
High Performer - Summer 2025
Regional Leader - Summer 2025
Easiest To Do Business With - Summer 2025
Best Meets Requirements- Summer 2025
Rate the form
4.4
Satisfied
59 Votes

For pdfFiller’s FAQs

Below is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

It's easy to make your eSignature with pdfFiller, and then you can sign your pebb premium surcharge attestation right from your Gmail inbox with the help of pdfFiller's add-on for Gmail. This is a very important point: You must sign up for an account so that you can save your signatures and signed documents.
Create, edit, and share pebb premium surcharge attestation from your iOS smartphone with the pdfFiller mobile app. Installing it from the Apple Store takes only a few seconds. You may take advantage of a free trial and select a subscription that meets your needs.
With the pdfFiller Android app, you can edit, sign, and share pebb premium surcharge attestation on your mobile device from any place. All you need is an internet connection to do this. Keep your documents in order from anywhere with the help of the app!
PEBB premium surcharge attestation is a form that employees must complete to attest to whether they have access to other qualifying health coverage for themselves and their dependents.
Employees who are enrolled in a PEBB medical plan and have dependents enrolled in the plan are required to file the PEBB premium surcharge attestation.
Employees can fill out the PEBB premium surcharge attestation form online through their PEBB account or by submitting a paper form to their employer.
The purpose of the PEBB premium surcharge attestation is to determine if the employee is eligible for the PEBB premium surcharge or if they have access to other qualifying health coverage.
Employees must report whether they and their dependents have access to other qualifying health coverage, such as through a spouse's employer-sponsored plan.
Fill out your pebb premium surcharge attestation online with pdfFiller!

pdfFiller is an end-to-end solution for managing, creating, and editing documents and forms in the cloud. Save time and hassle by preparing your tax forms online.

Get started now
Form preview

Pebb Premium Surcharge Attestation is not the form you're looking for?Search for another form here.

Related Features

Faint Effect in RPT with ease
Adjust Effect in Rtf with ease
Snip Result in STW with ease
Embed Result in UOF with ease
Paste Trace in ASC with ease

Relevant keywords

washington pebb attestation hca surcharges attestations erb smokefree checkboxes pebbs stateregistered reattest trs hcas retirees retiree debit cessation surcharge dependents subscribers applicable ump gov submitting subscriber attest isnt premiums enroll

Related Forms

Form preview
Tiny Tattler - National Association of Miniature Enthusiasts - miniatu
Tiny tattler region e-1 spring 2015 regional team regional coordinator mary myers 4391 adam court
Fill Now
Form preview
Application for seasonal employment - Pendleton Parks, Recreation ...
Application for seasonal employment 865 mutually rd, pendleton or 97801 phones: (541×2768100 fax: (541×2769789 date:
Fill Now
Form preview
TRAILER INTERCHANGE AGREEMENT
Trailer interchange agreement this agreement is entered into by and between panther ii transportation, inc.,
Fill Now
Form preview
Payment and Credit Card Charge Authorization - Automechanika ...
Apr 1, 2015 global experience specialists, inc. (ges) bank of america p.o. box 96174,
Fill Now
Form preview
Notice of Intent to Use EAC and Policies and Procedures
Notice of intent to use eac and policies and procedures l3 to be completed by
Fill Now
Form preview
Moonlight Mall Madness - Elkford Chamber of Commerce
Wildcat days 2015 craft & trade fair registration form saturday, june 27th, 10.00am5.00pm elk ford
Fill Now
Form preview
reformed youth services
After high school, then what? leaders guide and student questions discussion material for high school
Fill Now
If you believe that this page should be taken down, please follow our DMCA take down process here .
This form may include fields for payment information. Data entered in these fields is not covered by PCI DSS compliance.