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 2021 MyBenefits Summary
  
• Active 2020 MyBenefits Summary
• Special District 2021 MyBenefits Summary
  
• Special District 2020 MyBenefits Summary

Kaiser Permanente (KP)

• HMO Evidence of Covera​ge
  
• High Deductible HMO Evidence o​f Coverage
  
• Kaiser HMO SBC - 2021
• Kaiser HDHP HMO SBC - 2021
  

Sutter Health Plus (SHP)

• HMO Evidence of Coverage
  
• High Deductible HMO Evidence o​f Coverage   
  
• Evidence of Coverage - Infertility Rider
• Sutter HMO SBC - 2021
• Sutter HDHP HMO SBC - 2021
  

• Evidence of Coverage​
  
• Infertility Benefit
• WHA HMO SBC - 2021
• WHA HDHP HMO SBC - 2021
• 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 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 2021 MyBenefits Summary​
  
• 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 Applicatio​n​
  

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)

• HMO Evidence of Covera​ge
  
• High Deductible HMO Evidence o​f Coverage
• Senior Advantage $15 Evidence o​f Coverage
• Senior Advantage $25 Evidence o​f Coverage​
  
• Kaiser HMO SBC - 2021
• Kaiser HDHP HMO SBC - 2021
  
• Summary of Benefits​
  
• Medicare Overview
  

• HMO Evidence of Coverage
  
• High Deductible HMO Evidence o​f Coverage   
  
• Evidence of Coverage - Infertility Rider   
• Sutter HMO SBC - 2021
• Sutter HDHP HMO SBC - 2021 
  

United HealthCare (UHC)

• HMO Evidence of Coverage
  
• PPO Evidence of Cove​rage
  
• HMO Plan Guide
  
• PPO Plan Guide​
  

Western Health Advantage (WHA)

• Evidence of Coverage​
  
• Infertility Benefit
  
• WHA HMO SBC - 2021
• WHA HDHP HMO SBC - 2021
• ​Employee only
• ​Family
  

Vision Service Plan (VSP) 

• VSP Vision Care
  
• Coverage Details

Principal Financial (DENTAL)

• 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