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Benefit Forms
Employee Health Benefits- CalPERS Plans
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2023 Benefit Election Form
2022 Benefit Election Form
Decline Coverage Acknowledgment Form
Questionnaire for Disabled Dependent Benefit (HBD-98)
CalPERS Medical Plan Election/Change Form (HBD12)
Instructions for CalPERS Medical Plan Enrollment Form HBD12
Affidavit of Parent-Child Relationship Form (HBD-40)
Medical Report for the CalPERS Disabled Dependent Form (HBD-34)
Other CalPERS Forms and Publications
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Affidavits/Declarations
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Declaraton of Dependent Tax Status
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Deferred Compensation
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Deferred Compensation Plan Forms
Valic Mutual Fund Rollover/Transfer Out Form
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Disability Insurance
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The Standard LTD Certificate of Coverage
LTD Claim Instructions
LTD Claim Instruction and FAQ
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Consolidated Omnibus Budget Reconciliation Act (COBRA)
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2023 COBRA Election Form
2023 COBRA Rate Sheet
Notice of Rights and Obligations
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Flexible Spending Account
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Dependent Care FSA Plan Document
Healthcare FSA Plan Document
Cafeteria Plan Document
ASI Account Login
ASI Direct Deposit Application
Benny (Debit) Card Application
Letter of Medical Necessity
Other ASI Forms
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Life Insurance - Standard
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Standard Life - Coverage Conversion Package
Certificate of Coverage 641685-F (SEIU/LIUNA)
Certificate of Coverage 641685-E (Other)
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Miscellaneous Forms/ Information
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Employee Status Change Form
Medical Eye Services Claim Form
VSP Vision Claim Form
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Retiree Health Benefits
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Retiree Benefits Guide
2020 Retiree Benefit Election Form
2020 COBRA Benefit Election Form
United HealthCare Medicare Enrollment Form
United HealthCare Medicare Cancellation Form
Kaiser Senior Advantage (KPSA) Enrollment Form
Kaiser Senior Advantage Disenrollment Form
SCAN Medicare Enrollment Form
SCAN Disenrollment Form
Retiree Change Form
Cancel Retiree Health Benefits
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Retirement Forms & Publications
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Retirement Forms & Publications
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CalPERS Forms & Publications
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CalPERS Forms & Publications Center
Hospital Network
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