Human Resources - Benefit Forms


2014 Health Benefit Rates
2014 Parttime Employees Health Benefit Rates
2014 Evidence of Coverage Publications

ACA Covered California Marketplace

Tax Sheltered Annuity
TSA Salary Amendment Agreement
TSA Vendor List
Meaningful Notice
Third Party Administrator

457 Plan
457 Plan Benefit Designation Form
457 Plan Participant Change Authorization Form
457 Plan New Enrollment Form

2013 Health Benefit Rates

2014 Health Benefit Summary
Health Benefit Plan Enrollment/Change Form


Delta Dental Benefit Highlights
Delta Dental Voluntary Enrollment Form
Delta Care Enrollment/Change Form

United Healthcare Vision Brochure
United Healthcare Vision Enrollment Form (.doc)
United Healthcare Vision Easy Benefit Access Flyer
United Healthcare Vision Laser Vision Correction Flyer
United Healthcare Vision Online ID Card Flyer

Vision Service Plan Membership Enrollment Form
Vision Service Plan Coverage List

Part Time Employees
2013 Health Benefit Rates