Benefits Forms
Benefits Enrollment/Change Form (New Hire/Family Status Change)
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
Health Insurance Coverage Options and your Health Coverage
Authorization to Use/Disclose Personal Health Plan Information
Leave of Absence Request Form
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
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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