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.