Benefits Forms & Publications

• Benefits Enrollment Worksheet (PDF or Word)
• Declaration of Health Coverage (.pdf)
• CalPERS Disabled Dependent Benefit form (HBD-98)
• Medical Report for the CalPERS Disabled Dependent Benefit form (HBD-34)
• Economically Dependent Child - Affidavit of Eligibility Form

• Physicians (Unit 1)
• CSUEU Support Services (Units 2,5,7, and 9)
• Faculty (Unit 3)
• Academic Support (Unit 4)
• Skilled Craft (Unit 6)
• Public Safety (Unit 8)
• Teaching Associates (Unit 11)
• Management Personnel Plan (MPP)
• Confidentials (C99)
• Benefits and Leave Programs summary Grid

• Delta Dental PPO- Evidence of Coverage Brochure
• DeltaCare USA- Evidence of Coverage Brochure Basic Plan
• DeltaCare USA- Evidence of Coverage Brochure Enhance Plan

• Flex Cash Brochure

Dependent Care Reimbursement Account (DCRA)
website: http://www.asiflex.com/default.aspx

• DCRA Enrollment Form
• DCRA and HCRA (combined brochure)
• DCRA Brochure
• DCRA Claim Form

• HCRA Enrollment Form
• DCRA and HCRA (combined brochure )
• HCRA Brochure
• HCRA Claim Form

• Employer Paid Group Life Insurance Beneficiary Form - Standard Life Ins.
• Employer Paid Group Life Insurance Certificate - Standard Life Ins.
• Voluntary Life Insurance Beneficiary Form - Standard Life Ins.
• Voluntary Life Insurance Certificate - Standard Life Ins.

• Employer Paid Standard LTD Certificate
• Voluntary Standard LTD Certificate

• Pre- Tax Parking Brochure

• State Member Benefits (State Misc & State Safety)
• Requesting an Estimate
• Service Credit Purchase
• Service Retirement Election Application
• Applying for Disability Retirement
• Life Events - What You Need to Know
• CalPERS Videos
• Community Property Issues
• Leaving CalPERS Membership
• Power of Attorney (CalPERS Form & Publication)
• CalPERS Beneficiary Designation Form (CalPERS-BSD-241)
• Working and Benefits after Retirement

• CSU Systemwide TSA Information (eff. 1-1-09)
• Maximum Contribution Worksheet 2008 (PDF or Word)
• Maximum Contribution Worksheet 2008 (Auto Calculation)
  

• Vision Brochure (Certificate of Coverage)
• Vision Claim Form - Not required when using standard in-network benefits (see Vision Benefits for details).
• Vision - VSP Out-of-Network Reimbursement Form (.pdf)
• Vision - VDT Claim Form
• Vision- Locating a provider