Cancellation of supplemental life insurance (SEBB) 2021

20-0192

Use this form if you are a School employee and you wish to cancel your supplemental life and/or accidental death and dismemberment (AD&D) insurance.

Form

Cancellation of supplemental life insurance (SEBB) 2022

20-0192

Use this form if you are a school employee and you wish to cancel your supplemental life and/or accidental death and dismemberment (AD&D) insurance.

Form

Certification of a Child with a Disability (SEBB) 2021

20-0061

After turning 26, your dependent may be eligible for enrollment under your SEBB coverage. Use this form to certify your dependent's disability and enroll them on your SEBB coverage.

Form

Certification of a Child with a Disability (SEBB) 2022

20-0061

After turning 26, your dependent may be eligible for enrollment under your SEBB coverage. Use this form to certify your dependent's disability and enroll them on your SEBB coverage.

Form

Certification of a Child with Disability (PEBB) 2021

50-0142

After turning 26, your dependent may be eligible for enrollment under your PEBB coverage. Use this form to certify your dependent's disability and enroll them on your PEBB coverage.

Form

Coverage when you travel (PEBB)

Public Employees Benefits Board (PEBB) Program health plans have agreements with health providers at many destinations. This helps you get the medical care you may need. Contact your plan before you travel to find out about your options.

Publication

Davis Vision (SEBB) Certificate of Coverage (COC) 2021

This benefits book describes what is covered as a SEBB member under Davis vision, including vision services and specific services not covered by the plan. Finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays.

Publication

Davis Vision (SEBB) preauthorization requirements

Preauthorization requirements for Davis Vision plan. Preauthorization is when you seek approval from your health plan for coverage of specific services, supplies, or drugs before receiving them. Some services or treatments (except emergencies) may require preauthorization before the plan pays for them. These criteria do not imply or guarantee approval. Please check with your plan to ensure coverage. Preauthorization requirements are only valid for the month published. They may have changed from previous months and may change in future months.

Publication

Declaration of Tax Status (PEBB) 2021

50-0704

Employees and retirees must complete and submit this form with their enrollment form when enrolling an individual on their PEBB Program coverage who does not qualify as their dependent for federal tax purposes.

Form

Declaration of Tax Status (SEBB) 2021

20-0087

School Employees and SEBB Continuation Coverage must complete and submit this form with their enrollment form when enrolling an individual on their SEBB Program coverage who does not qualify as their dependent for federal tax purposes.

Form

Pages