Retired Member Signup Form (For Additional Benefits)

RETIRED MEMBER SIGNUP FORM (FOR ADDITIONAL BENEFITS)

Effective July 13, 2024, the base SEBA retired dues increased to $15.50 per month. This increase is being attributed to rising expenses with the facilitation of membership benefits. If you decide to remain a retired member, any other benefits such as AFLAC and NYLife life insurance you are presently enrolled in, will continue. You will also continue to receive free notary services and access to discount tickets to movie theaters and theme parks.
I authorize the Sheriff’s Employees’ Benefit Association (SEBA) to deduct the amount indicated below from each payroll warrant for pay period beginning
Member Name*

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

MonthDayYear
Date
Select your option(s)*

Chiropractic for retiree - $10 / monthChiropractic for retiree and spouse - $25 / monthPrime Fitness for retiree - $10 / monthPrime Fitness for retiree and spouse - $25 / month
If you opted to include your spouse in any of the above options please fill out the following information.

(Spouse is your legally married partner or registers domestic partner as recognized by the State of California.)
Spouse's Name

First NameLast Name
Spouse's Date of Birth

MonthDayYear
Date
Did you signup for Prime Fitness?

(Please read)
If you selected a Prime Fitness option and you were not currenlty enrolled please be advised, Prime Fitness membership activation can take up to two weeks. Visit www.primemember.com and click on “Sign Up” often to check status.

Once activated, you may download and print your Prime Fitness membership card(s). Take that card to the participating fitness facility of your choice. For Prime Fitness customer service call 1-877-238-6240, or SEBA at 909-885-6074.
SEBA USE ONLY
Processed By:
Date Processed:*

MonthDayYear
Date
Should be Empty:

RETIRED MEMBER SIGNUP FORM (FOR ADDITIONAL BENEFITS)

I authorize the Sheriff’s Employees’ Benefit Association (SEBA) to deduct the amount indicated below from each payroll warrant for pay period beginning

If you opted to include your spouse in any of the above options please fill out the following information.

Did you signup for Prime Fitness?

SEBA USE ONLY