benefit forms
Active Employee Plans
- 2020 Changes
- 2020 Benefit Options
- Benefits Summary (Medical Plans Comparison)
- Benefit Services Summary
- Employee Paid Medical Rates
- Medical
- ABOUT Generic Drugs
- Best Doctors
- Kaiser Care now at a Target Near You
- Kaiser Traveling Flyer
- UHC Journey Harmony HRA Deductible Flyer
- HealthInvest HRA
- Preventative Care Services
- VEBA Welcome Flyer
- VEBA Member App Flyer
- VEBA Healthy Reboot Flyer
- VEBA Well Being Services
- Medical Plan Summaries
- Kaiser Benefits Summary
- United HealthCare Network 1 Summary of Benefits Coverage
- United HealthCare Network 2 Summary of Benefits Coverage
- United HealthCare Journey Harmony Summary of Benefits Coverage
- United HealthCare Alliance HMO 20-30 Summary of Benefits Coverage
- United HealthCare Non-Differential Summary of Benefits Coverage
- United HealthCare Out-of Area EPO Summary of Benefits Coverage
- United HealthCare Out-of Area PPO Summary of Benefits Coverage
- VEBA Out of Area Dependent Benefits
- Medical Forms
- Dental
- Delta Dental Mobile
- Dental Plan Summary
- Dental Forms
- Vision
- Acupuncture/Chiropractic
- OptumHealth Acupuncture & Chiropractic Benefits
- Acupuncture & Chiropractic $10 Schedule of Benefits
- Acupuncture & Chiropractic $20 Schedule of Benefits
- Acupuncture & Chiropractic $30 Schedule of Benefits
- Express Scripts Prescriptions (UHC Plans only)
- Express Scripts HMO Alliance Co-Payments
- Express Scripts Prescription Overview
- Express Scripts Home Delivery
- Express Scripts Network 1 Co-Payments
- Express Scripts Network 2 Co-Payments
- Express Scripts Network 3 Co-Payments
- Express Scripts PPO Co-Payments
- Employee Assistance Program
- Hyatt Legal Plan
Beneficiary Designation Forms
- Beneficiary Designation for Deceased Employee
- CalPERS Beneficiary Designation
- Recipient Designation Form CalSTRS
Minnesota Life Insurance
- Group Term Life Insurance Policy
- Group Term Life Insurance Policy Amendment #1
- Group Term Life Certificate of Insurance
- Supplemental Life Welcome Packet (12-Month Employee)
- Supplemental Life Welcome Packet (11-Month Employee)
- Supplemental Life Welcome Packet (10-Month Employee)
- Life Enrollment Form
- Minnesota Beneficiary Designation Form
- Life Evidence of Insurability Form
- Conversion & Portability Comparison
- Minnesota Life Portability Form
- Minnesota Life Conversion Form
Domestic Partner
- Overview of Health Coverage for Domestic Partners
- Affidavit of Domestic Partnership
- Health Care Enrollment Statement
Flexible Spending Account (FSA) administered by Benefit Coordinators Corporation (BCC)
- Account Brochure
- Debit Card Request Form
- Direct Deposit Form
- Eligible Expenses
- FSA Plans: Grace Period
- My SmartCare Mobile App
- Notice of Change or Termination
- Over-the-Counter (OTC)
- Reimbursement Request Form
- SmartCare Registration
Commuter Benefit
- Account Brochure
- Transportation Request for Medical Reimbursement
- Transportation and Parking Enrollment
- Parking and Transportation Reimbursement Form
General Benefit Forms
Insurance Waiver
Long Term Disability Insurance (for Classified Contract Employees Only)