Cancel or Reduce Benefit Form
Name
*
First Name
Last Name
Email
*
example@example.com
Employee ID #
*
Cancel the following SEBA Benefit Deduction(s):
NY Life Voluntary AD&D Insurance
NY Life Voluntary Group Life Insurance
NY Life Voluntary Spouse Insurance
NY Life Voluntary Child
Chiropractic Member
Chiropractic Spouse
Prime Fitness Member
Prime Fitness Spouse
Legal Shield Service
All Legal Shield Coverage
Only the following:
Long Term Care Member
Long Term Care Spouse
Other:
Reduce the following SEBA Insurance(s):
NY Life Voluntary Group Life Insurance
NY Life Voluntary Spouse Life Insurance
NY Life Voluntary AD&D Insurance
By signing your name in the following box you agree to the above changes in your benefits:
Signature
SEBA USE ONLY
Processed by:
Date Processed:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: