Benefit Forms

Documents

Employee Benefits Record Form (PDF)

2019 Employee Benefits Matrix (PDF)

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

2019 CalPERS Summary of Benefits and Coverage Notice (PDF)

457 Deferred Compensation Beneficiary Designation Form (PDF)

457 Deferred Compensation Contribution Change Form (PDF)

457 Deferred Compensation Enrollment Form (PDF)

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

457 Deferred Compensation Rollover Form (PDF)

CalPERS Affidavit of Parent Child Relationship form (PDF)

CalPERS Beneficiary Designation Form (PDF)

CalPERS Medical Report For Disabled Dependent Benefit (PDF)

CalPERS Questionnaire For Disabled Dependent (PDF)

Commuter Benefits Program (PDF)

Domestic Partner Imputed Income Declaration (PDF)

FSA Enrollment Form (PDF)

Medical Waiver Premium Plan - Cash In Lieu (PDF)

Voluntary Life Insurance Enrollment Form (PDF)