Landmark Health Plan Chiropractic
AUTHORIZATION FORM TO ADD SPOUSE (ACTIVE MEMBERS ONLY)
I authorize the Sheriff’s Employees’ Benefit Association (SEBA) to deduct $5.00 from each payroll warrant for pay period beginning
Pay Period Beginning
*
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Month
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Day
Year
Member Name
*
First Name
Last Name
Personal Email
*
example@example.com
Employee ID #
*
Today's Date
*
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Month
-
Day
Year
Date
Spouse's Name
*
First Name
Last Name
Spouse's Date of Birth
*
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Month
-
Day
Year
Date
PLEASE READ:
Chiropractic signups are processed in the first full week of each month which is when the benefit becomes active. Once your request is approved you will receive a link to find a provider in your area.
SEBA USE ONLY
Processed By:
Date Processed:
*
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Month
-
Day
Year
Date
Submit
Should be Empty: