WebPEBB benefit number (P#####), OR#, University ID or Lottery ID Gender ... • I understand that I must renew this attestation each plan year and applicable tax year for which I want the Opt Out to apply. ... If you enroll in a Medical plan and do not complete this Section a tobacco surcharge ($25.00 per employee and $25.00 ... WebNext an: find out provided it must to attest Getting the Premium Surcharge Attestation Help Sheet (pdf) to determine if thee required pay the additional. Spousal coverage surcharge Washington State Health Care Authority Legal Notices Iona University
PEBB Premium Surcharge Attestation Change Form …
WebSep 11, 2014 · If you have a surcharge collected from your paycheck which you do not think applies to you, you may complete and submit the Premium Surcharge Attestation form to the HRS office at 139 French Administration, mail to Campus Zip 1014, fax to 509-335-1259 or email to [email protected]. Your request will go into effect the first of the month following … WebNov 3, 2024 · If required, you must attest by November 30, 2024. If you are required to attest but do not, or if your attestation results in incurring the premium surcharge, you will be charged the $50 spouse or SRDP coverage premium surcharge in addition to your monthly medical premium starting January 1, 2024. semco indigo 6 ma10a sewing machine white
PEBB Program policy 31-2: Use of PEBB premium surcharge …
WebAn attestation that results in a premium surcharge will take effect the same date as SEBB medical begins. Note: A school employee who waives SEBB medical as described in WAC 182-31-080 is not required to provide an attestation and no premium surcharge will be applied to their account as long as the school employee remains in waived status. WebPEBB Domestic Partner Affidavit is a partnership between an eligible employee and an individual of the opposite sex, or same sex without a Certificate of Registered Domestic Partnership. If you are adding a new domestic partnerby affidavit you must submit an affidavit along with this form to your payroll/HR benefit office. semco houghton