Benefits Unit
Benefit Forms and Plan Documents
Benefit Provider Contact Information
Employee Forms
- Employee Benefit Enrollment/Change Form
- 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
Extra Help Forms
Retiree Forms
Documents
Summary of Benefits and Coverage (SBC)
- Kaiser Permanente Traditional HMO
- Kaiser Permanente Hospital Services DHMO
- Kaiser Permanente Deductible First HDHP
- Kaiser Permanente Northwest Traditional HMO
- Kaiser Permanente Hawaii Traditional HMO
- Sutter Health Plus Traditional HMO
- Sutter Health Plus Hospital Services DHMO
- Sutter Health Plus Deductible First HDHP
- Western Health Advantage Traditional HMO
- Western Health Advantage Hospital Services DHMO
- Western Health Advantage Deductible First HDHP Self
- Western Health Advantage Deductible First HDHP Family
- County Health Plan EPO
- County Health Plan PPO
Evidence of Coverage (EOC)
- Kaiser Permanente Traditional HMO
- Kaiser Permanente Hospital Services DHMO
- Kaiser Permanente Deductible First HDHP
- Kaiser Permanente Northern California Senior Advantage
- Kaiser Permanente Northwest Traditional HMO
- Sutter Health Plus Traditional HMO
- Sutter Health Plus Hospital Services DHMO
- Sutter Health Plus Deductible First HDHP
- Western Health Advantage
- Delta Dental
- Vision Service Plan (VSP)