Active:

• Universal Enrollment Form (for changes/additions/deletions of ALL dependents)
• Universal Enrollment Form  (Active, Eligible Retirees)
• Universal Enrollment Form (for PTF w/o REP and TEA for 6 months plus 1 day employment status)
• Universal Enrollment Form  (PTF)
• CalPERS Health Plan Enrollment for Employees - Form HBD-12 (ALSO needed for changes/additions/deletions of ALL dependents)
• when enrolling/adding a Spouse or Domestic Partner: 
  • CalPERS Affidavit of Marriage and Domestic Partnership - Form PERS HBSD-1965 (To be used in lieu of Marriage Certificate; Domestic Partners Must Complete)
• when enrolling/adding a Child: 
  • CalPERS Affidavit of Parent-Child Relationship - Form HBD-40 (To be used in lieu of Birth Certificate; Passport accepted)
  • CalPERS Disabled Dependent Questionnaire - Form HBD-98 (if applicable)
  • CalPERS Disabled Dependent Medical Certification - Form HBD-34 (if applicable)

Retiree:

• CalPERS Health Benefits Enrollment Form
• CalPERS Certification of Medicare Status
• Retiree Change of Address Form
• Electronic Fund Transfer (EFT) Information
• Electronic Fund Transfer (EFT) Authorization - administrated by Discovery Benefits (To be used by Eligible retirees, Retired Board of Trustees and Surviving Spouse only)

Direct Pay:

• CalPERS Direct Payment Authorization(form PERS-HBD-21)This form is required for: a) non-qualified retirees of FHDA to enroll into a medical plan directly with CalPERS, b) individuals who become "self-paying", due to a leave of absence, or other authorizations related directly to CalPERS.

• CalPERS Direct Pay Plan Guide
• Transition Steps for Non-Pay status Benefits Eligible Part-time Faculty

Change of Address:

• CalPERS Address Change Authorization Form

Medical Claim Form:

• Anthem Blue Cross Member Claim Form - Medical

Prescription Drugs (RX):

• OptumRX Mail Order Service
• OptumRx Claim Form
• OptumRx Prescription Reimbursement Request Form
• OptumRX Prior Authorization Request Form

Dental:

• Delta Dental Claim Form

Group Term Life Insurance:

• Hartford Insurance Death Claim form
• Hartford Beneficiary Designation Form
• Hartford Life Portability Application Form
• Hartford Notice of Conversion Form

Supplemental Term Life Insurance:

• Supplemental Life and AD&D Application-Personal Health Form *
• Hartford Beneficiary Designation Form *
• Hartford Insurance Death Claim form

  *NOTE: these forms are mandatory

Flexible Spending Accounts (FSA Medical), Dependent Care (DCA), & Transportation Spending Account(TSA)

• Discovery Benefits FSA Enrollment Form

• Discovery Benefits FSA Claim Form

Important Deadline for FSA claims submission:

Deadline to apply for FSA reimbursement of expenses incurred for the Plan Year 2019 (January – December) with WageWorks: March 31, 2020. For PY 2020, the deadline is March 31, 2021 with Discovery Benefits.

Discovery Benefits replaces WageWorks as the new Third-Party Administrator effective January 1st, 2020.

*Terminated employees must submit FSA claim form within 90 days from the last day of active coverage.

Workers Compensation:

To be completed by the injured worker(The worker may be assisted by health services):

• DWC-1
• Workers' Comp Report of Injury Form
• State of California Employer's Report Form(Form 5020)

To be completed by the injured worker's supervisor:

• Supervisor's Claim and Safety Report

Long-Term Disability:

• Hartford Buy-Up Long Term Disability Enrollment Form (LTD)
• Hartford Buy-Up Long-Term Disability Claim Form
• Hartford Buy-Up Long-Term Disability Insurance Insurance Premium Rates and Payroll Authorization Form

C.O.B.R.A.:

• Universal Enrollment Form

  You must complete the Universal Enrollment Form AND the appropriate form below to enroll into C.O.B.R.A.

• Active Employees
• Retirees