Forms – SCMEBF

Forms

Forms

Beneficiary

Death Notification Form 84.1 KB MetLife Voluntary Life Beneficiary Form 953.7 KB

Claims

Beneficiary Forms - Active 115.4 KB Dental Claim Form (ADA) 214.9 KB Health Insurance Assistance Claim Form (2024) 245.8 KB Prescription Claim Form 239.4 KB Specialist Claim Form (2024) 254.6 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

Life Insurance Conversion Form

Life Conversion - NY 658.8 KB Life Conversion - Outside NY 170.5 KB

Misc

Change of Address Form 256.0 KB Check Replacement Affidavit 76.0 KB Opt-Out, Opt-Back-In Form 1-15-26 92.7 KB

Presentations

New Employee Presentation - PRINT (2 per pg) 2.5 MB Retiree Seminar Presentation (2 per pg) 1,018.9 KB

Retiree Self-Pay (Sperp)

SPERP Enrollment Form (2026 Rates) 155.0 KB SPERP Enrollment Packet (2026 Rates) 252.3 KB

Statement of Dependence

Statement of Dependence Application - Custodial 181.7 KB Statement of Dependence Application - Medical 228.2 KB