Certification of a child with a disability (SEBB) 2020

20-0061

After turning 26, your dependent may be eligible for enrollment under your SEBB coverage. Use this form to certify your dependent's disability and enroll them on your SEBB coverage.

Form

Declaration of tax status (SEBB) 2020

School Employees and SEBB Continuation Coverage must complete and submit this form with their enrollment form when enrolling an individual on their SEBB Program coverage who does not qualify as their dependent for federal tax purposes.

Form

Electronic debit service agreement (EDS) (SEBB) 2020

20-0045

Electronic Debit Service (EDS) is only available to continuously enrolled self-pay SEBB subscribers. Electronic service allows SEBB subscribers to have monthly payments automatically taken from a checking or savings account.

Form

Extended dependent certification (SEBB) 2020

20-0084

Submit this form with your enrollment form if you are enrolling an extended (legal) dependent child.

Form

MetLife cancellation of supplemental life and AD&D insurance (SEBB)

Use this form if you are a School employee and you wish to cancel your supplemental life and/or accidental death and dismemberment (AD&D) insurance.

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MetLife enrollment form (SEBB) 2020

Use this enrollment form to enroll in supplemental life and supplemental accidental death & dismemberment insurance.

Form

Premium payment plan election/change (SEBB) 2020

Complete this form if you do not want to pay your medical premiums with pretax earnings.

Form

Premium surcharge attestation help sheet (SEBB) 2020

20-0040

This is the 2020 SEBB Premium Surcharge Attestation Help Sheet. Use the information on this help sheet to attest on your enrollment form or the Premium Surcharge form whether the premium surcharges for tobacco use or spouse/state-registered domestic partner apply.

Form

SEBB Continuation Coverage (COBRA) Election/Change Form 2020

20-0060

Use this form to enroll in or change your enrollment options for SEBB Continuation Coverage (COBRA) coverage.

Form

SEBB Continuation Coverage (Unpaid Leave) Election/Change Form 2020

20-0059

Use this form to enroll in or change your enrollment options for SEBB Continuation Coverage (Unpaid Leave) coverage.

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