Benefits
Forms & Publications
Welcome to the Benefits Forms page!
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!
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
Parking
Flexible Spending
Medical Leave Request - Faculty, Staff & MPP
Non-Medical Leave Request - Staff & MPP
Family and Medical Leave (FMLA) Catastrophic Leave Donation Program (CLDP) Nonindustrial Disability Insurance (NDI) Pregnancy Disability
Family and Medical Leave (FMLA) Catastrophic Leave Donation Program (CLDP) Nonindustrial Disability Insurance (NDI) Pregnancy Disability