Benefit Forms and Plan Documents
For Employees
Forms
- Employee Benefit Enrollment/Change Form - Revised 6/1/21
- Employee FSA Enrollment Form
- Employee Supplemental Life Enrollment/Change Form - Revised 6/24/21
- Life Insurance Beneficiary Form
- Life Insurance Beneficiary Form - Spousal Consent, as applicable
- Staff Development Reimbursement eForm
- P & A Group Health Reimbursement Arrangement (HRA) Form
- Domestic Partner Affidavit (ESC, SCDPDAA and SEIU only)
Documents
Employee Benefits Contact Sheet
Summary of Benefits and Coverage (SBC)
- Kaiser Permanente TraditionalHMO
- Kaiser Permanente Hospital Services DHMO
- Kaiser Permanente Deductible First HDHP
- Kaiser Permanente Northwest Traditional
- HMOSutter Health Plus TraditionalHMO
- Sutter Health Plus Hospital Services DHMO
- Sutter Health Plus Deductible First HDHP
- Western Health Advantage TraditionalHMO
- Western Health Advantage Hospital Services DHMO
- Western Health Advantage Deductible First HDHP Self
- Western Health Advantage Deductible FirstHDHP Family
- County Health Plan EPO
- County Health Plan PPO
For Extra Help
For Retirees
- 2021-2022 Plan Year - Retiree Benefits Enrollment Change Form
- Retiree HRA Premium Reimbursement Auto-Pay Request Form
- Kaiser Permanente Senior Advantage Enrollment Form
- Kaiser Permanente Senior Advantage Disenrollment Form
- Western Health Advantage MyCare Enrollment Form
- Life Insurance Beneficiary Form