Forms & Publications
Welcome to the Benefits Forms page!
Please feel free to contact our department at (559) 278.2032, if you are unable to locate a Benefit form you need!
Benefits
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
- Vision Reimbursement Form (Out-of-network)
- Vision VDT Claim Form
FlexCash
Parking
Flexible Spending
- HCRA and DCRA Enrollment Form 2019
- HCRA and DCRA Claim Form 2019
- HCRA Debit Form 2019
- HCRA Brochure 2019
- DCRA Brochure 2019
Fee Waiver
Leaves
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
Pre-Tax Plans (403b, 401k, 457)