Cancel or Reduce Benefit Form

Cancel or Reduce Benefit Form
Name*

First NameLast Name
Email*
example@example.com
Employee ID #*
Cancel the following SEBA Benefit Deduction(s):
NY Life Voluntary AD&D InsuranceNY Life Voluntary Group Life InsuranceNY Life Voluntary Spouse InsuranceNY Life Voluntary Child
Chiropractic MemberChiropractic Spouse
Prime Fitness MemberPrime Fitness Spouse
Legal Shield Service

All Legal Shield CoverageOnly the following:
Long Term Care MemberLong 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

Clear
SEBA USE ONLY
Processed by:
Date Processed:

MonthDayYear
Date
Should be Empty:

Cancel the following SEBA Benefit Deduction(s):