Landmark Health Plan Chiropractic (SEBA Staff)

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

MonthDayYear
Employee Name

First NameLast Name
Work Email
example@example.com
Employee ID #
Today's Date

MonthDayYear
Date
Spouse's Name

First NameLast Name
Spouse's Date of Birth

MonthDayYear
Date
SEBA USE ONLY
Processed By:
Date Processed:

MonthDayYear
Date
Effective Date:
Should be Empty:

Landmark Health Plan Chiropractic