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2024 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). State
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How to fill out pebb premium surcharge change

01
To fill out the PEBB premium surcharge change, follow these steps:
02
Visit the PEBB website or contact the PEBB customer service to obtain the necessary forms.
03
Fill out your personal information, including your name, address, and contact details.
04
Provide your PEBB identification number and any other required identification information.
05
Indicate the reason for the premium surcharge change, whether it is a life event or a change in coverage.
06
Specify the effective date of the surcharge change and any other relevant details.
07
Sign and date the form, ensuring all information is accurate and complete.
08
Submit the completed form to the appropriate PEBB office or online portal as instructed.
09
Keep a copy of the filled-out form for your records.

Who needs pebb premium surcharge change?

01
Anyone who is enrolled in PEBB (Public Employees Benefits Board) and requires a change in their premium surcharge needs to complete the PEBB premium surcharge change form. This includes individuals who have experienced a life event, such as marriage, divorce, birth of a child, or loss of other coverage, as well as those who need to modify their surcharge due to a change in their coverage eligibility or level.
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PEBB premium surcharge change refers to adjustments made to the surcharges applied to Public Employees' Benefits Board (PEBB) plan members' premiums based on specific criteria or changes in policy.
Employers participating in the PEBB program who need to report changes affecting the premium surcharge for their employees must file the PEBB premium surcharge change.
To fill out the PEBB premium surcharge change, employers need to complete the designated forms provided by the PEBB program, accurately detailing changes and including necessary supporting documentation.
The purpose of the PEBB premium surcharge change is to ensure that health insurance premiums reflect accurate member risk assessments and comply with PEBB policies.
Information that must be reported includes employee identifiers, details of the surcharge changes, reasons for the changes, and any relevant supporting data.
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