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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 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)

Navia Benefit Solutions Forms and Publications webpage

Dependent certifications

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