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Get the free PEBB Premium Surcharge Change Form (50-0563)

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Clear form2023 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 (CRDP).
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How to fill out pebb premium surcharge change

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How to fill out pebb premium surcharge change

01
Log in to your PEBB account on the official website
02
Navigate to the 'Premium Surcharge Change' section
03
Select the appropriate option for the change you want to make (increase or decrease)
04
Enter the necessary information requested, such as reason for change, effective date, and supporting documentation if required
05
Review the changes before submitting and confirm the update

Who needs pebb premium surcharge change?

01
Employees who want to make changes to their PEBB premium surcharge
02
Employers who need to update employee premium surcharge information
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The pebb premium surcharge change is an adjustment made to the premium surcharge for PEBB program participants.
Employers and individuals enrolled in the PEBB program are required to file the pebb premium surcharge change.
To fill out the pebb premium surcharge change, individuals need to provide accurate information about changes in their premium surcharge.
The purpose of pebb premium surcharge change is to ensure that participants are paying the correct premium surcharge based on their eligibility.
Information such as changes in income, household size, and other factors affecting premium surcharge must be reported on the pebb premium surcharge change form.
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