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Benefits Forms 

Benefits Enrollment/Change

A worksheet for employees to designate their medical, dental, and FlexCash options

CalPERS Affidavit of Marriage
Allows certification of marriage when no marriage certificate is available.
Describes the process for requesting catastrophic leave donations
A CalPERS required form for enrolling into or opting out of benefits. Do NOT mail directly to CalPERS – send to the Benefits Coordinator in Human Resources
Used by employees if a Delta Dental provider does not bill directly for services
Dependent Care/Health Care Reimbursement Account
The CSU Health Care Reimbursement Account, a voluntary benefit for eligible employees offers you the ability to pay for eligible out-of-pocket health care expenses with pre-tax dollars.  The Health care Reimbursement Account offers you the ability to apply for an FSA Benny Master Card which functions as a debit card for paying out-of-pocket expenses.

Form used to submit claims against a Dependent Health Care Reimbursement Account or a Health Care Reimbursement Account   

Information regarding Covered California and Health Coverage Offered by Cal Maritime.
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
·         Voluntary AD&D Insurance
·         Voluntary Life Insurance
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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