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 & Dental Enrollment
- Benefits Worksheet (New Hire) Last names A - L
- Benefits Worksheet (New Hire) Last names M - Z
- Benefits Worksheet ACA Last Names A - L
- Benefits Worksheet ACA Last Names M - Z
- Benefits Worksheet (Family Status Change) Last names A - L
- Benefits Worksheet (Family Status Change) Last names M - Z
Vision Plan Premier Enrollment
- 2025 VSP Premier Enrollment Form Last Names A - L
- 2025 VSP Premier Enrollment Form Last Names M - Z
- Vision Reimbursement Form (Out-of-network)
- Vision VDT Claim Form
Other Resources
- Affidavit of Marriage/Domestic Partnership
- Affidavit of Parent-Child Relationship (HBD-40)
- Domestic Partnership Certification
- Domestic Partnership Taxable Income for Benefits
- Process to Continue Benefits for Disabled Dependent beyond Age 26
- 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
- Catastrophic Leave Donation Program (CLDP) Donation Form
- Request for Participation Form - Please contact the Leave Coordinator, Jennifer Olsen, for Participation Form
- Summary
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 and Non-Medical Leave Requests - Faculty, Staff, MPP & FERP - Please contact
the Leave Coordinator, Jennifer Olsen, for Medical Leave Request form