Benefits Forms
Current employees submit completed forms to the Department of Human Resources:
Benefits Enrollment/Change Form
Benefits Accounts Receivable (A/R) Form
ACA Benefits Enrollment/Change Form
Declaration of Health Care Coverage
CalPERS Affidavit of Marriage/Domestic Partnership
CalPERS Affidavit of Parent-Child Relationship
Dependent/Health Care Reimbursement Account (DCRA/HCRA) Form
Direct Payment Authorization Form – CalPERS Health
Fee Waiver Application - Employee
Fee Waiver Application - Dependent
Authorization to Use/Disclose Personal Health Plan Information
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 Form
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
To designate or change the beneficiary of the employer-paid Life and AD&D benefit.
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.