CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM
You must submit
a completed enrollment form and any required documentation to the DHRM-Risk & Benefits Division within 60 days of your initial
benefits eligibility date or within 60 days of a qualified change in family status.
APPLICATION TYPE
Marriage / New Domestic Partnership / Divorce
YOUR PERSONAL INFORMATION
Last Name First Name Middle Initial
Street Address Apt. # City
State
Zip
Last four of Social Security
Number or Employee I
D
#
Birth Date Phone Number Gender
Male Female
EMPLOYMENT INFORMATION
Department Name Job Class Rep Unit FT PPT Sworn
CHOOSE YOUR VISION PLAN NON-SWORN ONLY *
Waive Dental Coverage
Vision Service Plan*
TO ADD OR DROP DEPENDENTS FROM YOUR BENEFITS, PLEASE COMPLETE THE BELOW
You must submit required eligibility documentation for and provide SSN for enrollment of all dependents. See the reverse side of this form for details of required
documentation..
Medical Dental Vision Last Name First Name MI FULL SSN Date of Birth
Relationship
LIFE INSURANCE (NON-SWORN EMPLOYEES ONLY)
I appoint as revocable beneficiary(-ies) of insurance payable
in the event of my death:
(Contingent beneficiaries are in the event if death of all primary
beneficiaries)
I certify that information on this document is true and correct and I give the person(s) administering the plans in which I enroll and/or their agents permission to verify any and all information. I agree to assume full
financial responsibility for all expenses and to reimburse and indemnify the plans and the City of Oakland for any benefits paid for me and/or my dependents if I or my dependents subsequently prove to be
ineligible to participate in the plans or to receive such benefits. I also understand that the falsification of information on this document may violate applicable laws, rules and regulations and could lead to
disciplinary action, dismissal and/or legal action. I have read and accept the terms and conditions on this side and the reverse side of this form.
EFECTIVE DATE:
Primary Care Physician
Physician ID#
Ensure you verify your physician participates in the plan you selected
PCP VERIFICATION DATE:
IAFF Sworn Fire
(Indemnity Dental)
Delta Dental*
Delta
Care USA *
Sworn Police OPOA Dental
CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM
You must submit
a completed enrollment form and any required documentation to the DHRM-Risk & Benefits Division within 60 days of your initial
benefits eligibility date or within 60 days of a qualified change in family status.
APPLICATION TYPE
Rehire / Reinstatement Birth / Adoption Marriage / New Domestic Partnership / Divorce Open Enrollment New Hire
Loss of Coverage Other-Please explain:
YOUR PERSONAL INFORMATION
Last Name First Name Middle Initial
Street Address Apt. # City
State
Zip
Last four of Social Security
Number or Employee I
D
#
Birth Date Phone Number Gender
Male Female
EMPLOYMENT INFORMATION
Department Name Job Class Rep Unit FT PPT Sworn
CHOOSE YOUR VISION PLAN NON-SWORN ONLY *
Waive Dental Coverage
Vision Service Plan* Waive Vision Coverage
TO ADD OR DROP DEPENDENTS FROM YOUR BENEFITS, PLEASE COMPLETE THE BELOW
You must submit required eligibility documentation for and provide SSN for enrollment of all dependents. See the reverse side of this form for details of required
documentation..
Medical Dental Vision Last Name First Name MI FULL SSN Date of Birth
Relationship
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Primary:
Name Relationship % of Benefit
Name Relationship % of Benefit
LIFE INSURANCE (NON-SWORN EMPLOYEES ONLY)
I appoint as revocable beneficiary(-ies) of insurance payable
in the event of my death:
(Contingent beneficiaries are in the event if death of all primary
beneficiaries) Contingent:
Name Relationship % of Benefit
Name Relationship % of Benefit
I certify that information on this document is true and correct and I give the person(s) administering the plans in which I enroll and/or their agents permission to verify any and all information. I agree to assume full
financial responsibility for all expenses and to reimburse and indemnify the plans and the City of Oakland for any benefits paid for me and/or my dependents if I or my dependents subsequently prove to be
ineligible to participate in the plans or to receive such benefits. I also understand that the falsification of information on this document may violate applicable laws, rules and regulations and could lead to
disciplinary action, dismissal and/or legal action. I have read and accept the terms and conditions on this side and the reverse side of this form.
Your Signature: Date:
PERS ENTRY:
ORACLE ENTRY:
EFECTIVE DATE:
PLEASE SEE THE REVERSE SIDE OF THIS FORM FOR ADDITIONAL INFORMATION
Primary Care Physician
Physician ID#
Ensure you verify your physician participates in the plan you selected
PCP VERIFICATION DATE:
IAFF Sworn Fire
(Indemnity Dental)
Delta Dental*
Delta
Care USA *
Sworn Police OPOA Dental
CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM
You must submit
a completed enrollment form and any required documentation to the DHRM-Risk & Benefits Division within 60 days of your initial
benefits eligibility date or within 60 days of a qualified change in family status.
APPLICATION TYPE
Rehire / Reinstatement Birth / Adoption Marriage / New Domestic Partnership / Divorce Open Enrollment New Hire
Loss of Coverage Other-Please explain:
YOUR PERSONAL INFORMATION
Last Name First Name Middle Initial
Street Address Apt. # City
State
Zip
Last four of Social Security
Number or Employee I
D
#
Birth Date Phone Number Gender
Male Female
EMPLOYMENT INFORMATION
Department Name Job Class Rep Unit FT PPT Sworn
CHOOSE YOUR VISION PLAN NON-SWORN ONLY *
Waive Dental Coverage
Vision Service Plan* Waive Vision Coverage
TO ADD OR DROP DEPENDENTS FROM YOUR BENEFITS, PLEASE COMPLETE THE BELOW
You must submit required eligibility documentation for and provide SSN for enrollment of all dependents. See the reverse side of this form for details of required
documentation..
Medical Dental Vision Last Name First Name MI FULL SSN Date of Birth
Relationship
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Primary:
Name Relationship % of Benefit
Name Relationship % of Benefit
LIFE INSURANCE (NON-SWORN EMPLOYEES ONLY)
I appoint as revocable beneficiary(-ies) of insurance payable
in the event of my death:
(Contingent beneficiaries are in the event if death of all primary
beneficiaries) Contingent:
Name Relationship % of Benefit
Name Relationship % of Benefit
I certify that information on this document is true and correct and I give the person(s) administering the plans in which I enroll and/or their agents permission to verify any and all information. I agree to assume full
financial responsibility for all expenses and to reimburse and indemnify the plans and the City of Oakland for any benefits paid for me and/or my dependents if I or my dependents subsequently prove to be
ineligible to participate in the plans or to receive such benefits. I also understand that the falsification of information on this document may violate applicable laws, rules and regulations and could lead to
disciplinary action, dismissal and/or legal action. I have read and accept the terms and conditions on this side and the reverse side of this form.
Your Signature: Date:
PERS ENTRY:
ORACLE ENTRY:
EFECTIVE DATE:
PLEASE SEE THE REVERSE SIDE OF THIS FORM FOR ADDITIONAL INFORMATION
Primary Care Physician
Physician ID#
Ensure you verify your physician participates in the plan you selected
PCP VERIFICATION DATE:
IAFF Sworn Fire
(Indemnity Dental)
Delta Dental*
Delta
Care USA *
Sworn Police OPOA Dental
CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM
You must submit
a completed enrollment form and any required documentation to the DHRM-Risk & Benefits Division within 60 days of your initial
benefits eligibility date or within 60 days of a qualified change in family status.
APPLICATION TYPE
Rehire / Reinstatement Birth / Adoption Marriage / New Domestic Partnership / Divorce Open Enrollment New Hire
Loss of Coverage Other-Please explain:
YOUR PERSONAL INFORMATION
Last Name First Name Middle Initial
Street Address Apt. # City
State
Zip
Last four of Social Security
Number or Employee I
D
#
Birth Date Phone Number Gender
Male Female
EMPLOYMENT INFORMATION
Department Name Job Class Rep Unit FT PPT Sworn
CHOOSE YOUR VISION PLAN NON-SWORN ONLY *
Waive Dental Coverage
Vision Service Plan* Waive Vision Coverage
TO ADD OR DROP DEPENDENTS FROM YOUR BENEFITS, PLEASE COMPLETE THE BELOW
You must submit required eligibility documentation for and provide SSN for enrollment of all dependents. See the reverse side of this form for details of required
documentation..
Medical Dental Vision Last Name First Name MI FULL SSN Date of Birth
Relationship
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Primary:
Name Relationship % of Benefit
Name Relationship % of Benefit
LIFE INSURANCE (NON-SWORN EMPLOYEES ONLY)
I appoint as revocable beneficiary(-ies) of insurance payable
in the event of my death:
(Contingent beneficiaries are in the event if death of all primary
beneficiaries) Contingent:
Name Relationship % of Benefit
Name Relationship % of Benefit
I certify that information on this document is true and correct and I give the person(s) administering the plans in which I enroll and/or their agents permission to verify any and all information. I agree to assume full
financial responsibility for all expenses and to reimburse and indemnify the plans and the City of Oakland for any benefits paid for me and/or my dependents if I or my dependents subsequently prove to be
ineligible to participate in the plans or to receive such benefits. I also understand that the falsification of information on this document may violate applicable laws, rules and regulations and could lead to
disciplinary action, dismissal and/or legal action. I have read and accept the terms and conditions on this side and the reverse side of this form.
Your Signature: Date:
PERS ENTRY:
ORACLE ENTRY:
EFECTIVE DATE:
PLEASE SEE THE REVERSE SIDE OF THIS FORM FOR ADDITIONAL INFORMATION
Primary Care Physician
Physician ID#
Ensure you verify your physician participates in the plan you selected
PCP VERIFICATION DATE:
IAFF Sworn Fire
(Indemnity Dental)
Delta Dental*
Delta
Care USA *
Sworn Police OPOA Dental
CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM
You must submit
a completed enrollment form and any required documentation to the DHRM-Risk & Benefits Division within 60 days of your initial
benefits eligibility date or within 60 days of a qualified change in family status.
APPLICATION TYPE
Rehire / Reinstatement Birth / Adoption Marriage / New Domestic Partnership / Divorce Open Enrollment New Hire
Loss of Coverage Other-Please explain:
YOUR PERSONAL INFORMATION
Last Name First Name Middle Initial
Street Address Apt. # City
State
Zip
Last four of Social Security
Number or Employee I
D
#
Birth Date Phone Number Gender
Male Female
EMPLOYMENT INFORMATION
Department Name Job Class Rep Unit FT PPT Sworn
CHOOSE YOUR VISION PLAN NON-SWORN ONLY *
Waive Dental Coverage
Vision Service Plan* Waive Vision Coverage
TO ADD OR DROP DEPENDENTS FROM YOUR BENEFITS, PLEASE COMPLETE THE BELOW
You must submit required eligibility documentation for and provide SSN for enrollment of all dependents. See the reverse side of this form for details of required
documentation..
Medical Dental Vision Last Name First Name MI FULL SSN Date of Birth
Relationship
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Primary:
Name Relationship % of Benefit
Name Relationship % of Benefit
LIFE INSURANCE (NON-SWORN EMPLOYEES ONLY)
I appoint as revocable beneficiary(-ies) of insurance payable
in the event of my death:
(Contingent beneficiaries are in the event if death of all primary
beneficiaries) Contingent:
Name Relationship % of Benefit
Name Relationship % of Benefit
I certify that information on this document is true and correct and I give the person(s) administering the plans in which I enroll and/or their agents permission to verify any and all information. I agree to assume full
financial responsibility for all expenses and to reimburse and indemnify the plans and the City of Oakland for any benefits paid for me and/or my dependents if I or my dependents subsequently prove to be
ineligible to participate in the plans or to receive such benefits. I also understand that the falsification of information on this document may violate applicable laws, rules and regulations and could lead to
disciplinary action, dismissal and/or legal action. I have read and accept the terms and conditions on this side and the reverse side of this form.
Your Signature: Date:
PERS ENTRY:
ORACLE ENTRY:
EFECTIVE DATE:
PLEASE SEE THE REVERSE SIDE OF THIS FORM FOR ADDITIONAL INFORMATION
Primary Care Physician
Physician ID#
Ensure you verify your physician participates in the plan you selected
PCP VERIFICATION DATE:
IAFF Sworn Fire
(Indemnity Dental)
Delta Dental*
Delta
Care USA *
Sworn Police OPOA Dental
CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM
You must submit
a completed enrollment form and any required documentation to the DHRM-Risk & Benefits Division within 60 days of your initial
benefits eligibility date or within 60 days of a qualified change in family status.
APPLICATION TYPE
Rehire / Reinstatement Birth / Adoption Marriage / New Domestic Partnership / Divorce Open Enrollment New Hire
Loss of Coverage Other-Please explain:
YOUR PERSONAL INFORMATION
Last Name First Name Middle Initial
Street Address Apt. # City
State
Zip
Last four of Social Security
Number or Employee I
D
#
Birth Date Phone Number Gender
Male Female
EMPLOYMENT INFORMATION
Department Name Job Class Rep Unit FT PPT Sworn
CHOOSE YOUR VISION PLAN NON-SWORN ONLY *
Waive Dental Coverage
Vision Service Plan* Waive Vision Coverage
TO ADD OR DROP DEPENDENTS FROM YOUR BENEFITS, PLEASE COMPLETE THE BELOW
You must submit required eligibility documentation for and provide SSN for enrollment of all dependents. See the reverse side of this form for details of required
documentation..
Medical Dental Vision Last Name First Name MI FULL SSN Date of Birth
Relationship
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Add Drop Add Drop Add Drop
Primary:
Name Relationship % of Benefit
Name Relationship % of Benefit
LIFE INSURANCE (NON-SWORN EMPLOYEES ONLY)
I appoint as revocable beneficiary(-ies) of insurance payable
in the event of my death:
(Contingent beneficiaries are in the event if death of all primary
beneficiaries) Contingent:
Name Relationship % of Benefit
Name Relationship % of Benefit
I certify that information on this document is true and correct and I give the person(s) administering the plans in which I enroll and/or their agents permission to verify any and all information. I agree to assume full
financial responsibility for all expenses and to reimburse and indemnify the plans and the City of Oakland for any benefits paid for me and/or my dependents if I or my dependents subsequently prove to be
ineligible to participate in the plans or to receive such benefits. I also understand that the falsification of information on this document may violate applicable laws, rules and regulations and could lead to
disciplinary action, dismissal and/or legal action. I have read and accept the terms and conditions on this side and the reverse side of this form.
Your Signature: Date:
PERS ENTRY:
ORACLE ENTRY:
EFECTIVE DATE:
PLEASE SEE THE REVERSE SIDE OF THIS FORM FOR ADDITIONAL INFORMATION
Primary Care Physician
Physician ID#
Ensure you verify your physician participates in the plan you selected
PCP VERIFICATION DATE:
IAFF Sworn Fire
(Indemnity Dental)
Delta Dental*
Delta
Care USA *
Sworn Police OPOA Dental
CHOOSE YOUR DENTAL PLAN NON-SWORN ONLY*
Health Net SmartCare
Blue Shield Access
Blue Shield Trio
Western Health Advantage
United Healthcare
PERS Choice PPO*
PERS Select PPO*
Anthem HMO Traditional
Kaiser
Anthem HMO Select
PERSCare PPO*
*Administered by Anthem BlueCross
CHOOSE YOUR HEALTH PLAN
You must live in a covered service area to enroll in these plans. Please refer to the CalPERS Health Benefit Summary to
confirm service areas or visit http://www.calpers.ca.gov.
PORAC (Sworn Police)
Waive Medical Coverage
(OPOA are not eligible)
