Forms

SEBB Forms

SEBB Employee Request for Review/Notice of Appeal Form
https://www.hca.wa.gov/assets/pebb/20-0161-sebb-employee-request-for-review-notice-of-appeal.pdf

SEBB Employee Change Form
https://www.hca.wa.gov/assets/perspay/20-0127-School-Employee-Change-2021.pdf

SEBB Premium Surcharge Attestation Help Sheet
https://www.hca.wa.gov/assets/pebb/20-0040-sebb-premium-surcharge-attestation-help-sheet-2021.pdf

SEBB Premium Surcharge Attestation Change Form
https://www.hca.wa.gov/assets/pebb/20-0041-premium-surcharge-attestation-change-form-2021.pdf

2021 SEBB Spousal Plan Calculator
https://www.hca.wa.gov/assets/pebb/20-0042-sebb-spousal-plan-calculator-2021.pdf

SEBB Declaration of Tax Status 2021
https://www.hca.wa.gov/assets/pebb/20-0087-sebb-declaration-of-tax-status-2021.pdf

SEBB Extended Dependent Certification 2021
https://www.hca.wa.gov/assets/pebb/20-0084-sebb-extended-dependent-certification-2021.pdf

SEBB Certification of a Child with a Disability 2021
https://www.hca.wa.gov/assets/pebb/20-0061-sebb-certification-child-with-disability-2021.pdf

HSA Deduction Form 2021 (Begin a deduction, Change your deduction, Stop your deduction)
https://www.hca.wa.gov/assets/pebb/20-0086-school-employee-hsa-deduction-authorization-2021.pdf

HSA Beneficiary Designation Form
https://healthequity.com/doclib/forms/beneficiary.pdf

SEBB Continuation Coverage (COBRA) Election/Change Form 2021
https://www.hca.wa.gov/assets/pebb/20-0060-sebb-continuation-coverage-election-change-cobra-2021.pdf

SEBB Continuation Coverage (Unpaid Leave) Election/Change Form 2021
https://www.hca.wa.gov/assets/pebb/20-0059-sebb-continuation-coverage-election-change-unpaid-leave-2021.pdf

 

MetLife Forms - Life Insurance

MetLife Enrollment/Change Form
https://www.hca.wa.gov/assets/pebb/sebb-metlife-enrollment-form.pdf

MetLife Beneficiary Form * Employer Name is WA State Health Care Authority SEBB and Customer Number is 219743
https://www.hca.wa.gov/assets/perspay/sebb-metlife-beneficiary-form.pdf

*Change your supplemental coverage amounts or update beneficiaries online
https://online.metlife.com/edge/web/public/benefits/index?groupNumber=219743

 

Navia Forms - FSA/DCAP

FSA/DCAP Enrollment Form for Newly Eligible Staff Only
https://portal.naviabenefits.com/pdf/SEBB/SEBB_Midyear_Enrollment_Form.pdf

FSA/DCAP Enrollment Form for Staff Approved for Special Open Enrollment Event
https://docs.naviabenefits.com/files/SEBB-Change-in-Status-Form.pdf

FSA/DCAP Claim Form
https://portal.naviabenefits.com/pdf/SEBB/SEBB_Claim_Form.pdf

DCAP Recurring Claim Form
https://portal.naviabenefits.com/pdf/SEBB/SEBB_DCAP_Recurring_Claim_Form.pdf

FSA/DCAP Termination Form
https://portal.naviabenefits.com/pdf/SEBB/SEBB_Term_Form.pdf

FSA/DCAP Transfer Form (When you resign with Tahoma but go to work for another Washington School District-SEBB Benefits transfer with you.)
https://portal.naviabenefits.com/pdf/SEBB/SEBB_School_Employment_Transfer_Form.pdf


The Standard Forms-Supplemental LTD

Supplemental Long-Term Disability Enrollment and Change Form
https://www.standard.com/eforms/7533_756494.pdf

Supplemental Long-Term Disability Medical History Statement (Evidence of Insurability)
https://www.standard.com/eforms/16119_756494.pdf

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