Benefits
Forms & Publications
Welcome to the Benefits Forms page!
All Enrollment Benefit Forms need to be submitted using AdobeSign.
Below you will find forms that pertain to Health Benefits, Flexcash, Parking, Voluntary Benefits, the Fee Waiver, Family & Medical Leave, Catastrophic Leave, Nonindustrial Disability and Pregnancy Disability. Click on the Benefits, Fee Waiver or Leaves heading to view a full list of forms for that section.Please feel free to contact our department at (559) 278.2032, if you are unable to locate a Benefit form you need!
All Enrollment Benefit Forms will need to be submitted using AdobeSign.
Health Enrollment Forms
Health
- Affidavit of Marriage/Domestic Partnership
- Affidavit of Parent-Child Relationship (HBD-40)
- Cobra Continuation Election Form
- Domestic Partnership Certification
- Domestic Partnership Taxable Income for Benefits
- Process to Continue Benefits for Disabled Dependent beyond Age 26
- Cobra Continuation Election Form
Vision Plan
Other Resources
- Collection of Dependent Social Secuirty Numbers
- HIPAA Authorization to Use and/or Disclose Personal Health Plan Information
- Medical Non-Participating Tax Advantage Premium Plan (TAPP) form
Fee Waiver Application: Last name A-L
- Dependent Fee Waiver Application last name A-L
- Faculty and Staff Fee Waiver Application last name A-L
- Career Development Plan (CDP) Form last name A-L
Fee Waiver Application: Last name M-Z
Medical Leave Request - Faculty, Staff & MPP
Non-Medical Leave Request - Staff & MPP
Family and Medical Leave (FMLA)
Family and Medical Leave (FMLA)
- Employee - Certification of Healthcare Provider
- Family Member - Certification of Healthcare Provider