Forms

• • Enrollment Forms

  • e-Benefits Electronic Signature Authorization (OnBase/PolyDoc Form)
  • Open Enrollment Worksheet (OnBase/PolyDoc Form)

  • Voluntary Benefits Forms

  • Covered California Notice (PDF)
  • CSU Privacy Notice (PDF)
  • Flexible Spending Account (FSA) Debit Card Request Form (Optional for HCRA Plan Participants)
  • HCRA/DCRA Manual Claim Form (PDF)
  • The Standard’s Enrollment and Change Form (PDF)

  • Retirement Forms

  • Retirement Notice to Benefits (Web Form)
  • Declaration of Health Coverage (PDF)
  • Make an Appointment with CalPERS

  • DEV Forms

  • Affidavit of Parent-Child Relationship (PDF)
  • Affidavit of Marriage/Domestic Partnership (PDF)

  • Vision Forms

  • VSP Out-of-Network Reimbursement Form (PDF)
  • VSP Vision Care Premier Enrollment (PDF)
  • VSP Computer Vision Glasses Conformation Form (PDF)

  • Leave Forms 

  • CalPERS Request for Service Credit Information - Military Leave of Absence Service (PERS-MDS-369A) Form - This form is for new employees and those returning from a military leave to purchase their active duty military service credit through CalPERS.   
  • ECRL/COVID-19 Leaves