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)
2020 FSA Status Change Form
Request for Certificate of Coverage
Employee's Designation of Beneficiary Under Government Code 53245