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Forms and publications
When printing forms to share with employees, also provide the SEBB nondiscrimination statement and language access notice.
On this page
- Employee medical, dental, vision
- SEBB Continuation Coverage (COBRA and Unpaid Leave)
- Premium surcharges
- 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
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Employee medical, dental, vision
- School employee change form 2021
- School employee enrollment guide 2021
- School Employees Employee Enrollment Guide 2020
SEBB Continuation Coverage (COBRA and Unpaid Leave)
- SEBB Continuation Coverage Election Notice
- SEBB Continuation Coverage Election Notice Insert (for those currently enrolled in COBRA and will transition to SEBB Continuation Coverage)
- SEBB Continuation Coverage (COBRA) Election/Change form 2020
- SEBB Continuation Coverage (Unpaid Leave) Election/Change form 2020
Premium surcharges
- SEBB Premium Surcharge Attestation Help Sheet 2020 2021
- SEBB Premium Surcharge Attestation Change form 2020 2021
- Spousal Plan Calculator (print version) 2020 2021
- Spousal Plan Calculator (interactive tool) 2020 2021
Life and accidental death and dismemberment (AD&D) insurance
- MetLife life and AD&D insurance Certificate of Coverage (COC) 2020 (part-time employees)
- MetLife life and AD&D insurance Certificate of Coverage (COC) 2020 (full-time employees)
- MetLife Enrollment/Change form
- Beneficiary Designation form
- Cancellation of supplemental life and AD&D insurance form 2021
- Notification of enrollment extension for supplemental life form
- MetLife Privacy notice
- MetLife MIB PreNotice
Long-term disability (LTD) insurance
- LTD Open Enrollment (OE) enrollment/change form 2020
- LTD Certificate of Coverage (COC) 2020
- LTD Enrollment/Change form 2020
- LTD Evidence of Insurability
- LTD claim packet
- LTD error or discrepancy correction form
Health Savings Account (HSA)
- Employee Authorization for Payroll Deduction for HSA 2021
- Employee Authorization for Payroll Deduction for HSA 2020
- Beneficiary Designation
Medical Flexible Spending Arrangement (FSA) and Dependent Care Assistance Program (DCAP)
- Navia Benefit Solutions
- FSA & DCAP Open Enrollment Form (Oct 26-Nov 23, 2020)
