Administrative Services > Human Resources > Benefits > Forms > Forms & Brochures

A

• Affidavit of Parent-Child Relationship (HBD-40)
• Affidavit of Marriage/Domestic Partnership
• ASI Claim Form

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B

• Benefits Overviews
• Benefits Worksheet (Not for Open Enrollment)
  • Benefits Worksheet (Open Enrollment)
• Bereavement Leave
• Blue Shield
  • Blue Shield Advantage - Evidence of Coverage
  • Blue Shield Net Value Advantage - Evidence of Coverage
  • Physician Selection Form

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C

• CalPERS
  • Benefit Table
  • Completing the Disability Retirement Election Application
  • Completing the Service Retirement Application
  • Disabled Dependent Benefit Medical Report (HBD-34)
  • Disabled Dependent Benefit Member Questionnaire (HBD-98)
  • Disability Retirement Election Application
  • Planning Your Service Retirement
  • Refund-Rollover Election Information
  • Refund Tax Information
  • Service Credit Purchase Options
  • Service Retirement Election Application
  • State Member Benefits
  • When You Change Retirement Systems
• Catastrophic Leave Donation Program (CLDP)
  • Donation Chart
  • Summary
  • Option Sheet
• COBRA
  • Continuation Election Form
  • Description
  • Rates
    • 2012
• Collective Bargaining Agreements
  • Faculty
  • Staff
• Credit Unions

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D

• Declaration of Health Coverage (HBD-12A)
• Delta Dental
  • Claim Form
  • Plan Summary
• Dental Group Numbers
• Dental Summaries
  • Units 1, 2,3, 4, 5, 6, 7, 9, C99, M98, M80, and FERP Annuitants
  • Unit 10, and Teaching Associates
  • Units 8, E99, and Annuitants
• Dependent Care Reimbursement Account (DCRA)
  • ASI Claim Form
  • Brochure
  • HCRA and DCRA Enrollment Form
• Domestic Partnership
  • Certification
  • Domestic Partnership Taxable Income for Benefits

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E

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F

• Family and Medical Leave (FMLA)
  • Certification of Health Care Provider for Employee
  • Certification of Health Care Provider for Family Member
  • Certification of Health Care Provider for Paternity Leave
  • Notice and Request Form
  • Q & A
  • Employee Rights and Responsibilities
• FlexCash and TAPP Brochure
• FlexCash Enrollment Form

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H

• Health Care Reimbursement Account (HCRA)
  • ASI Claim Form
  • Brochure
  • HCRA and DCRA Enrollment Form
  • Health Care Reform Updates
  • Medical Expense Worksheet
  • Quick Facts
• Health Insurance Portability and Accountability Act (HIPAA)
  • HIPAA Authorization to Use and/or Disclose Personal Health Plan Information
  • HIPAA Privacy Policy 2004
  • HIPAA Privacy Notice 2012

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K

• Kaiser
  • Chiropractic Provider Directory
  • Evidence of Coverage

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L

• Leave of Absence Request
  • Request for Non-Medical Leave - Staff & MP
  • Medical Leave Application
• Life Insurance
  • Brochure
  • Certificate
  • Eligible Employee
• Long-Term Care Brochures
• Long Term Disability Insurance (LTD)
  • Brochure
  • Certificate
  • Eligible Employee
  • Reasonable Accommodation Expense Benefit
  • Return to Work Incentive/Child Care Expense Benefit
  • Right to Convert
  • Survivors Benefit

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M

• Maternity / Paternity / Adoption / Parental Leave
  • Chart
  • Website

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N

• Nonindustrial Disability (NDI)
  • Rate Chart
  • Summary
  • Provisions
• Non-Participating Tax Advantage Premium Plan (TAPP) form

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O

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P

• Part-Time Faculty Benefits Eligibility
• Part-time, Seasonal and Temporary Employees Retirement Program (PST)
  • Fact Sheet
  • PST Benefit Payment Booklet
• PERS Choice/PERS Care/PERS Select
  • Member Claim Form
  • PERS Care - Evidence Coverage
  • PERS Choice - Evidence of Coverage
  • PERS Select - Evidence of Coverage
• Pre-Tax Parking Deduction Plan
  • Brochure
  • Cancellation Form

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S

• Savings Plus (401(K) and 457) Plans
  • Comparison Chart

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T

• Tax Advantage Premium Plan (TAPP)
  • Brochure
  • Non-Participating Tax Advantage Premium Plan (TAPP) Form
• Tax Shelter Annuity Program (TSA) 403(b)
  • Comparison Chart
  • Maximum Catch-up Worksheet

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V

• Vision Service Plan (VSP) Benefits
  • Benefits Summary
  • Participating Provider Network
  • Reimbursement Form (Out-of-network)
  • VDT Claim Form

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