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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
- Premium surcharges
- Health Savings Account (HSA)
- Life and accidental death and dismemberment (AD&D) insurance
- Long-term disability (LTD) insurance
- Flexible Spending Arrangements (FSAs) and Dependent Care Assistance Program (DCAP)
- Dependent certifications
- SEBB Continuation Coverage (COBRA and Unpaid Leave)
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Employee medical, dental, vision
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
Life and accidental death and dismemberment (AD&D) insurance
- Certificate of Coverage (COC) 2020 (part-time employees)
- Certificate of Coverage (COC) 2020 (full-time employees)
- 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
- 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)
- Navia Benefit Solutions Forms and Publications webpage
Dependent certifications
- Declaration of Tax Status 2022
- Extended Dependent Certification 2022
- Certification of a Child with a Disability 2022