Benefit Forms

Documents

Employee Benefit Record Form (enrollment form) (PDF)

2019 Benefits Guide - Full-time & Permanent Part-time (PDF)

2019 Sworn Police Benefits Guide (PDF)

2019 Employee Benefits Matrix (PDF)

2020 Medical Plan Rates - Full-Time (PDF)

2020 Medical Plan Rates - Permanent Part-Time (PDF)

2019 Medical Plan Rates - Full Time (PDF)

2019 Medical Plan Rates-Permanent Part-Time (PDF)

2019 CalPERS Summary of Benefits and Coverage Notice (PDF)

Beneficiary Designation Form - 457 Deferred Compensation Plan (PDF)

Beneficiary Designation Form - CalPERS (PDF)

Beneficiary Designation Form - Life Insurance (Hartford) (PDF)

457 Deferred Compensation Contribution Change Form (PDF)

457 Deferred Compensation Rollover Form 2019 (PDF)

457 Deferred Compensation Enrollment Form (PDF)

457 Deferred Compensation Age 50/Pre-Retirement Catch-Up Change Form (PDF)

457 Deferred Compensation Pre-Retirement Catch-Up Form (PDF)

CalPERS Affidavit of Parent Child Relationship form (PDF)

CalPERS Medical Report For Disabled Dependent Benefit (PDF)

CalPERS Questionnaire For Disabled Dependent (PDF)

CalPERS 2020 Health Benefit Summary (PDF)

Commuter Benefits Program (PDF)

Domestic Partner Imputed Income Declaration (PDF)

FSA Enrollment Form 2020 (PDF)

FSA Summary Plan Description (PDF)

Medical Waiver Premium Plan - Cash In Lieu (PDF)

Voluntary Life Insurance Enrollment Form (PDF)