Health Plan Enrollment or Change Forms:
Medical/Dental/Vision (Non-Medicare Plans)
Non-Registered Domestic Partnership
Cancellation Forms:
Cancellation Notice for Self-Pay Health & Life Insurance
Payroll Deduction Cancellation Form - Voluntary Insurance
Waiver of Group Health Benefits
Other Forms:
2021 FSA Election Form (contributions for January to December 2021)
2021 FSA Election Change Form (Qualifying Event Required)
Request for Certificate of Coverage
Employee's Designation of Beneficiary Under Government Code 53245