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Forms

Beneficiary

Beneficiary Forms - Active 11-19-24 69.9 KB Beneficiary Forms - Retired Member 75.0 KB MetLife Voluntary Life Beneficiary Form 953.7 KB

Claims

ADA Dental Claim Form 214.9 KB Health Insurance Assistance Claim Form 156.7 KB Metlife Dental Claim Form 4.4 MB Metlife Short Term Disability Claim Form 423.7 KB Prescription Claim Form 209.6 KB Specialist Claim Form 112.8 KB

COBRA

COBRA Coverage Application 239.5 KB COBRA Coverage Pre-Payment Application 104.9 KB

Domestic Partner

Domestic Partner FULL Application 334.5 KB Domestic Partner Renewal Affidavit 104.8 KB Domestic Partner Termination Application 83.5 KB

Misc

Change of Address Form 256.0 KB Check Replacement Affidavit 76.0 KB Opt-Out, Opt-Back-In Form 7-21-23 95.3 KB Statement of Dependence Application - Custodial 181.7 KB Statement of Dependence Application - Medical 228.3 KB

Self Pay

SPERP Enrollment Packet (2024-25 Rates) 1-16-24 404.9 KB SPERP-Enrollment-Form-2024-25-Rates-1-31-24 165.7 KB

The Suffolk County Municipal Employee Benefit Fund

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Fri: 8AM – 4:30PM

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