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Get the free SEBB Premium Surcharge Change Form (20-0041)

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2024 SEBB Premium Surcharge Attestation Change Form Use this form to report a change that affects your premium surcharge for tobacco use or spouse or stateregistered domestic partner (SRDP). Stateregistered
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How to fill out sebb premium surcharge change

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How to fill out sebb premium surcharge change

01
Start by obtaining the SEBB premium surcharge change form.
02
Carefully read the instructions provided with the form to understand the requirements and process.
03
Fill out your personal information, such as name, address, and contact details.
04
Provide your SEBB employer details, including the agency name and contact information.
05
Indicate the reason for the premium surcharge change, whether it is due to a life event or a change in eligibility.
06
If applicable, provide proof of the qualifying life event or change in eligibility.
07
Complete the section regarding your dependent(s) and their insurance coverage.
08
Review all the information you have provided to ensure accuracy and completeness.
09
Sign and date the form.
10
Submit the completed form to the designated authority or department responsible for processing SEBB premium surcharge changes.

Who needs sebb premium surcharge change?

01
SEBB premium surcharge change is needed by individuals who are currently enrolled in the School Employees' Benefits Board (SEBB) program and wish to make alterations to their premium surcharge status.
02
These changes may be necessary due to various reasons, such as a qualifying life event (marriage, birth, adoption, divorce, etc.) or a change in eligibility for premium surcharge subsidies.
03
It is important for individuals who experience such changes to fill out the SEBB premium surcharge change form to ensure their premium surcharge status reflects their current circumstances.
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The SEBB premium surcharge change refers to adjustments in the surcharges applied to School Employees Benefits Board (SEBB) health insurance premiums based on specific criteria, such as the employee's tobacco use.
All school employees who are subject to the SEBB health insurance plan and may be impacted by the tobacco use surcharge are required to file the SEBB premium surcharge change.
To fill out the SEBB premium surcharge change, complete the designated form provided by the SEBB, providing necessary details such as personal information, tobacco use status, and any other required documentation.
The purpose of the SEBB premium surcharge change is to ensure that premium rates reflect the health risks associated with tobacco use, encouraging healthier choices among employees.
The information required includes the employee's name, address, date of birth, whether they use tobacco products, and any other relevant personal health information.
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