Landmark Health Plan Chiropractic
AUTHORIZATION FORM TO ADD SPOUSE (SEBA Staff)
I authorize the Sheriff’s Employees’ Benefit Association (SEBA) to deduct the amount indicated below from each payroll warrant for pay period beginning
This is a free benefit provided to members and their spouses.
Pay Period Beginning
*
-
Month
-
Day
Year
Employee Name
*
First Name
Last Name
Work Email
*
example@example.com
Employee ID #
*
Today's Date
*
-
Month
-
Day
Year
Date
Spouse's Name
*
First Name
Last Name
Spouse's Date of Birth
*
-
Month
-
Day
Year
Date
SEBA USE ONLY
Processed By:
Date Processed:
-
Month
-
Day
Year
Date
Effective Date:
Submit
Should be Empty: