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Benefits Forms 

Benefits Enrollment/Change Form 

Benefits Accounts Receivable (A/R) Form

ACA Benefits Enrollment/Change Form

Declaration of Health Care Coverage

CalPERS Affadavit of Marriage/Domestic Partnership

Delta Dental Claim

Dependent/Health Care Reimbursement Account (DCRA/HCRA) Form

Direct Payment Authorization Form – CalPERS Health

Health Insurance Coverage Options and your Health Coverage

Authorization to Use/Disclose Personal Health Plan Information

Leave of Absence Request Form

Health Insurance Coverage Options and Your Health Coverage
Information regarding Covered California and Health Coverage Offered by Cal Maritime.

HIPPA Authorization
An employee authorization for Human Resources staff to use and/or disclose personal health plan information to an approved agency.

Leave of Absence Request
For employees who wish to request a leave of absence for medical, family medical leave, parental, pregnancy, military, education, personal or other leaves.

Life and AD&D Beneficiary Designation and Change (Employer Paid)
To designate or change the beneficiary of the employer-paid Life and AD&D benefit.

NEW -- AD&D, Life, and Long-Term Disability Programs Offered by the Standard

Verification of Disability
Form for employee to give to the treating physician verifying a disability.

VSP Out-of-Network Reimbursement
Reimbursement form for employees who utilized the services of a non-VSP network provider.

VSP Video Display Terminal (VDT) Claim
Form for employees to give their vision provider when their job meets the requirements for the VDT benefit.

For more information about CSU Benefits refer to: CSU Benefits.

For more information about Family Medical Leave (FML) refer to: Leave Information. 

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Last updated: 9/24/20