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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

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

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)

Navia Benefit Solutions
FSA & DCAP Open Enrollment Form (Oct 26-Nov 23, 2020)

Dependent certifications