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
- 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 (SEIU only)
Extra Help Forms
Retiree Forms
- Retiree Enrollment/Change Form
- Retiree HRA Premium Reimbursement Auto-Pay Request Form
- P&A Group Direct Deposit Form
- Kaiser Permanente Senior Advantage Enrollment Form
- Kaiser Permanente Senior Advantage Disenrollment Form
- Western Health Advantage MyCare Enrollment Form
- Life Insurance Beneficiary Form
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)
- County Health Plans EPO & PPO Summary Plan Document (SPD)
- County Health Plans Formulary Drug List October 2023 - subject to change without notice
- County Health Plans Formulary Drug List January 2024 - subject to change without notice
- Kaiser Permanente Traditional HMO
- Kaiser Permanente Hospital Services DHMO
- Kaiser Permanente Deductible First HDHP
- Kaiser Permanente Hawaii Senior Advantage
- Kaiser Permanente Hawaii Traditional HMO
- 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 Employees
- Delta Dental Retiree PPO
- Delta Dental Retiree DeltaCare USA
- Vision Service Plan (VSP)
Summary Plan Description (SPD) and Drug Formulary List
Life Insurance Ceritifcates
Full Time Employees -
- UHC Life Class 2 - DSA (46, 47)
- UHC Life Class 3 - Confidential (51), Law Library Non-Management
- UHC Life Class 4 - Admin Management (50), BOS (49), Dept/Agency Heads (52), DSLEM (43), SCDPDAA (60), SCLEMA (44), SCPA (45), SCTA Management, Law Library Management
- UHC Life Class 5 - Local 39 (85), SEIU (01,05,10,25,80,95), SCLEA (30,40,41,70), SCPDIA (55)
- UHC Life Class 7 - ESC (75)
- UHC Life Class 10 - WCE (21)
- UHC Life Class 11 - Unrepresented (00), SCTA Non-Management
Part Time Employees -
- UHC Life Class 6 - SCLEA (30, 40, 41, 70)
- UHC Life Class 8 - ESC (75)
- UHC Life Class 9 - DSA (46,47)