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This version of the form is not currently in use and is provided for reference only. Download this version of
Form HCA20-0041
for the current year.
Form HCA20-0041 Sebb Premium Surcharge Attestation Change Form - Washington
What Is Form HCA20-0041?
This is a legal form that was released by the Washington State Health Care Authority - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form HCA20-0041?
A: Form HCA20-0041 is the Sebb Premium Surcharge Attestation Change Form in Washington.
Q: What is the purpose of Form HCA20-0041?
A: The purpose of Form HCA20-0041 is to make changes to the Sebb Premium Surcharge Attestation.
Q: Who needs to fill out Form HCA20-0041?
A: Employees in Washington who are enrolled in the School Employees Benefits Board (Sebb) Program and need to make changes to their premium surcharge attestation.
Q: What information is required on Form HCA20-0041?
A: Form HCA20-0041 requires personal information, such as name, address, and contact details, as well as details about the changes being made to the premium surcharge attestation.
Form Details:
- Released on September 1, 2021;
- The latest edition provided by the Washington State Health Care Authority;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form HCA20-0041 by clicking the link below or browse more documents and templates provided by the Washington State Health Care Authority.
Download Form HCA20-0041 Sebb Premium Surcharge Attestation Change Form - Washington
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