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Clear form2022 WEBB Premium Surcharge Attestation Change Form Use this form to report a change that affects your premium surcharge for tobacco use or spouse or state registered domestic partner. State
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How to fill out sebb premium surcharge attestation

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How to fill out sebb premium surcharge attestation

01
To fill out the SEBB Premium Surcharge Attestation, follow these steps:
02
Start by entering your personal information such as your name, address, and contact information.
03
Indicate whether you are an employee or a dependent.
04
Provide the necessary details about your employer or the employee’s employer.
05
Read the statements and accurately answer whether you or your dependent(s) use tobacco products.
06
If you or your dependent(s) use tobacco products, you may be subject to a premium surcharge.
07
Sign and date the attestation to confirm the information provided is true and accurate.

Who needs sebb premium surcharge attestation?

01
Anyone who is a participant in the SEBB Program (School Employees Benefits Board Program) or their dependents may need to fill out the SEBB Premium Surcharge Attestation. This includes school employees who are eligible for health insurance through the SEBB Program, as well as their dependents who are covered under the program. The attestation helps determine if an individual or their dependent(s) use tobacco products, which can result in a premium surcharge.
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SEBB premium surcharge attestation is a form used by employers to report the payment of SEBB premium surcharges on employees' health care coverage.
Employers who provide health care coverage to their employees and are subject to SEBB premium surcharges are required to file the attestation.
The attestation can be filled out online through the SEBB website or submitted via mail using the printed form.
The purpose of the attestation is to ensure that employers are accurately reporting and paying SEBB premium surcharges for their employees' health care coverage.
Employers must report the total number of employees, total hours worked, and the amount of SEBB premium surcharges paid.
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