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)

Find additional forms and documents on HealthEquity's website.

Life and accidental death and dismemberment (AD&D) insurance

Long-term disability (LTD) insurance

Flexible Spending Arrangements (FSAs) and Dependent Care Assistance Program (DCAP)

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