Due to COVID-19, HCA’s lobby is closed. Learn more about HCA's customer service options during the pandemic.

Forms and publications

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

Want to have SEBB materials delivered to your organization?

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 | 2022
  • SEBB Continuation Coverage (Unpaid Leave) Election/Change form 2021 | 2022

Premium surcharges

  • SEBB Premium Surcharge Attestation Help Sheet 2021 | 2022
  • SEBB Premium Surcharge Attestation Change form 2021 | 2022
  • Spousal Plan Calculator (print version) 2021 | 2022
  • Spousal Plan Calculator (interactive tool) 2021 | 2022

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 | 2022
  • SEBB Extended Dependent Certification 2021 | 2022
  • SEBB Certification of a Child with a Disability 2021 | 2022