Personnel Services

Current Employees

• Active Employee Enrollment Form
• Special District Employee Enrollment Form
• Waiver of Employer Coverage Affidavit - 2021
• Waiver of Employer Coverage Affidavit - 2020
• Active 2020 MyBenefits Summary
• Special District 2020 MyBenefits Summary

Kaiser Permanente (KP)

• Evidence of Coverage

• Kaiser HMO SBC - 2020
• Kaiser HDHP HMO SBC - 2020

Sutter Health Plus (SHP)

• HMO Evidence of Coverage
• Sutter HMO SBC - 2020
• High Deductible HMO Evidence of Coverage
• Sutter HDHP HMO SBC - 2020
• Evidence of Coverage - Infertility Rider

• Evidence of Coverage
• WHA HMO SBC - 2020
• Infertility Benefit
  
• WHA HDHP HMO SBC - 2020
• Employee only
• Family
  

Vision Service Plan (VSP) 

• VSP Vision Care
• Coverage Details

Health Savings Accounts (HSA)

• HSA Authorization Form
  
• Optum Designation of Beneficiary
  
• Optum Rollover Form
• Health Equity HSA Rollover Form
• Health Equity HSA Beneficiary Designation

Flexible Spending Accounts (FSA)

• FSA Claim Form
• Day Care Reimbursement Claim Form
• Orthondontia Reimbursement Claim Form
• Flex Plan Summary​

Delta Dental (Dental)

• Employee Dental Plan booklet

Life Insurance

• Your Group Life Insurance Certificate of Coverage
• Life Insurance Change Form (Actives)
• Life Insurance Beneficiary Designation
• Life Insurance Short Form - For Increases 
• SETA Life Insurance Form
• Life Insurance Form non-SETA​

Critical Illness

• Critical Illness Certificate of Coverage
• Critical Illness Application
• Critical Illness Health Statement Questionnaire

Retiree Health Savings Plan (RHSP)

• Retiree Health Savings Plan Document
• Employee Change Form​

529 College Savings Plan

• Direct Deposit Allocation Form​
  

Retirees

• Retiree 2020 MyBenefits Summary
• Retiree Enrollment Form
• Retiree Medical Administrative Policy
• Retiree Summary Flow Chart

Medicare Enrollment Forms

(Required in addition to the County form when enrolling in or switching between a Medicare Plan)

• Kaiser Senior Advantage Application

Medicare Disenrollment Forms

(Required in addition to the County form when dis-enrolling from or switching between a Medicare plan) 

• Kaiser Senior Advantage Disenrollment Form 

Kaiser Permanente (KP)

• Evidence of Coverage
• Kaiser HMO SBC - 2020
• Kaiser HDHP HMO SBC - 2020

• HMO Evidence of Coverage
• Sutter HMO SBC - 2020
• High Deductible HMO Evidence of Coverage     
• Sutter HDHP HMO SBC - 2020
• Evidence of Coverage - Infertility Rider     
  

United HealthCare (UHC)

• HMO Evidence of Coverage (2020)
• PPO Evidence of Coverage (2020)

Western Health Advantage (WHA)

• Evidence of Coverage
• WHA HMO SBC - 2020
• Infertility Benefit
• WHA HDHP HMO SBC - 2020
• Employee only
• Family

Vision Service Plan (VSP) 

• VSP Vision Care
  
• Coverage Details

Principal Financial (DENTAL)

• Retiree Dental POS Benefit Summary
• Principal Dental Evidence of Coverage - Standard Plan
• Principal Dental Evidence of Coverage - Enhanced Plan

Retiree Health Savings Plan (RHSP)

• Claim Form
• Eligibility Form
• Direct Deposit Authorization Form
• Decedent Information Form