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Forms and publications

When printing forms to share with employees, also provide the SEBB nondiscrimination statement and language access notice.

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Order materials

Employee medical, dental, vision

SEBB Continuation Coverage (COBRA and Unpaid Leave)

  • SEBB Continuation Coverage Election Notice 2021
  • Initial notice of COBRA and Continuation Coverage rights 2021
  • SEBB Continuation Coverage (COBRA) Election/Change form 2021
  • SEBB Continuation Coverage (Unpaid Leave) Election/Change form 2021

Premium surcharges

  • SEBB Premium Surcharge Attestation Help Sheet  2021
  • SEBB Premium Surcharge Attestation Change form  2021
  • Spousal Plan Calculator (print version) 2021
  • Spousal Plan Calculator (interactive tool) 2021

Life and accidental death and dismemberment (AD&D) insurance

Long-term disability (LTD) insurance

Health Savings Account (HSA)

Medical Flexible Spending Arrangement (FSA) and Dependent Care Assistance Program (DCAP)

Dependent certifications

  • SEBB Declaration of Tax Status  2021
  • SEBB Extended Dependent Certification  2021
  • SEBB Certification of a Child with a Disability 2021