Current employees submit completed forms to the Department of Human Resources:

Upload here

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

Delta Dental Claim

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

Military Difference in Pay

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.