North Benefits Advisor
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Note: Please do not send Protected Health Information (PHI) to the email address above. To initiate a Secure Communication email with your Advisor please login to mySEIB.
2022 Enrollment Form HCRA / DCRA
New Employee Enrollment (IB02) - New employees who wish to enroll or decline coverage and employees re-enrolling who are returning from LWOP
Retired Employee Enrollment (IB04) - Retirees who wish to enroll or decline coverage and retirees re-enrolling who had a break in coverage.
Active and Retired Employee Plan Change (IB14) - Active state employees and retirees change plans, change plans during open enrollment, and decline coverage. Active employees to re-enroll when coverage was declined.
