Forms & Publications

Open Enrollment Benefits Worksheet (DocuSign)
FlexCash Form 2022 (DocuSign)
Open Enrollment Flexible Spending Account for HCRA and/or DCRA (DocuSign)
VSP Premier - Click here to Enroll or dis-enroll in VSP Premier
Vitural Open Enrollment Step-By-Step Registration

All Enrollment Benefit Forms will need to be submitted using the following process MoveIt Instructions.

Health

• Affidavit of Marriage/Domestic Partnership
• Affidavit of Parent-Child Relationship (HBD-40)
• Benefits Worksheet (New Hire)
• Benefits Worksheet (Family Status Change)
• Blue Shield Physician Selection Form
• Cobra Continuation Election Form
• Disabled Dependent Benefit Medical Report (HBD-34)
• Disabled Dependent Benefit Member Questionnaire (HBD-98)
• Domestic Partnership Certification
• Domestic Partnership Taxable Income for Benefits
• HIPAA Authorization to Use and/or Disclose Personal Health Plan Information
• Medical Non-Participating Tax Advantage Premium Plan (TAPP) form
• Medical Report for the CalPERS DIsabled Dependent Benefit
• Member Questionnaire for the CalPERS Disabled Dependent Benefit
• Vision Reimbursement Form (Out-of-network)
• Vision VDT Claim Form

FlexCash

• FlexCash Form 
  
• FlexCash Brochure

Parking

• Pre-Tax Parking Deduction Plan Cancellation Form

Flexible Spending

• HCRA and DCRA Enrollment Form 2021
• HCRA and DCRA Claim Form  
• ASIFlex Quick Guide
• HCRA Brochure 
  
• DCRA Brochure

• Catastrophic Leave Donation Program (CLDP) Donation Form
• Request for Participation Form
• Summary
• MoveIt Instructions

• Admission Data Form
• Career Development Plan (CDP) Form
• Dependent Fee Waiver Application
• Faculty and Staff Fee Waiver Application

Medical Leave Request - Faculty, Staff & MPP

Non-Medical Leave Request - Staff & MPP

Family and Medical Leave (FMLA)

• Employee - Certification of Healthcare Provider
• Family Member - Certification of Healthcare Provider
• FML Rights and Responsibilities
• Notice and Request Form
• Paternity Leave - Certificate

Catastrophic Leave Donation Program (CLDP)

• Donation Form
• Request for Participation Form
• Summary

Nonindustrial Disability Insurance (NDI)

• NDI - How to file a claim
• NDI - Provisions
• NDI - Summary & Rate Chart

Pregnancy Disability

• Pregnancy - Certification of Health Care Provider
• Pregnancy - Notice B

403(b) Savings Made Easy
2021 Universal Notice
401k-457 Plan Comparison Chart 2021
CSU Supplemental Retirement Plan 403(b) Features 2021
CSU Supplemental Retirement Plan 403(b) Max Catch-Up Worksheet 2021