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Human Resources - Benefit Forms

2015 Health Benefits Summary - CALPERS

Health Benefits Plan
Delta Care HMO
Delta Dental
United Healthcare Vision
Vision Service Plan

2014 SMMUSD Health Benefit Rates – Certificated hired after 7/1/14
2014 Health Benefit Rates
2014 Parttime Employees Health Benefit Rates
2014 Medical Premiums for Certificated and Full time Classified hired 7/1/14

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

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

Santa Monica-Malibu Unified School District
1651 16th Street
Santa Monica, California 90404