Forms and publications
When printing forms to share with employees, also provide the SEBB nondiscrimination statement and language access notice.
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Medical, dental, and vision
Dependents
- Dependent verification: Policy 31-1
- Declaration of Tax Status form 2022
- Extended Dependent Certification form 2022
- Certification of a Child with a Disability form 2022
Premium surcharges
- Premium Surcharge Attestation Help Sheet 2022
- Premium Surcharge Attestation Change form 2022
- Spousal Plan Calculator (print version) 2022
- Spousal Plan Calculator (interactive tool) 2022
Health Savings Account (HSA)
- Employee Authorization for Payroll Deduction for HSA 2022
- Beneficiary Designation
Find additional forms and documents on HealthEquity's website.
Life and accidental death and dismemberment (AD&D) insurance
- Life and AD&D Administration Manual
- Certificate of Coverage (COC) (at least 630 hours)
- Certificate of Coverage (COC) (less than 630 hours)
- MetLife's MyBenefits portal
- Employees can use the MyBenefits portal to add/update beneficiaries and elect/change supplemental coverages.
- MetLife Enrollment/Change form
- Beneficiary Designation form
- Cancellation of supplemental life and AD&D insurance form 2022
- Notification of enrollment extension for supplemental life form 2022
- Privacy notice
Long-term disability (LTD) insurance
- LTD Administration Manual
- Plan Booklet 2022
- Enrollment/Change form 2022
- Evidence of Insurability
- Claim packet
- LTD error or discrepancy correction form 2022
Flexible Spending Arrangements (FSAs) and Dependent Care Assistance Program (DCAP)
- Midyear Enrollment form 2022
- FSA and DCAP Claim form 2022
- Change in Status form
- School Employment Transfer form
- FSA Termination form
Find additional forms and documents on Navia's website.
SEBB Continuation Coverage (COBRA and Unpaid Leave)
- Continuation Coverage Election Notice 2022
- Initial notice of COBRA and Continuation Coverage rights 2022
PEBB Retiree Insurance
- Retiree Enrollment Guide 2022