CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM
ENROLLMENT APPLICATION: TERMS AND CONDITIONS
Your signature on the front of this form signifies your authorization, understanding of and agreement to the following:
The City of Oakland
DHRM – Risk & Benefits Division
will only enroll you and your eligible dependents in the benefit elections indicated on this form
and for which you are eligible.
You agree to submit any contribution required on your part directly to the
City of Oakland
DHRM – Risk & Benefits Division during any unpaid leave of
absence.
Your participation in the City of Oakland sponsored benefits is subject to all applicable laws, rules and regulations (including but not limited to, the rules
and regulations of the City of Oakland) as the same may be amended, modified or supplemented from time to time.
You will not be able to make any changes to the benefit elections indicated on this form during the Plan year (January 1-December 31) unless you have a
qualifying family status change.
Coverage may be canceled at anytime. If you elect to waive/cancel your City of Oakland sponsored medical, dental or vision coverage, you may re-enroll
only during an Open Enrollment period, if you’ve experienced a recent (within 60 days) loss of other coverage, or be assessed a 90-day waiting period.
Any misstatement of fact made by you with respect to the eligibility of any dependent or any other matter contained on this form will make you subject to
disciplinary action, dismissal and/or legal action.
You authorize any person, hospital or other entity that has rendered medical or dental services to you or any dependent(s) listed on this form to make
available to the health plan, to such extent as may be lawful, any information, records or photographs regarding such services if requested by the health
plan. Such information may also be released to persons or entities which, in conjunction with, or at the direction of the medical plan are conducting a
review of cost, quality and/or appropriateness of services rendered.
You agree that if you or any dependent listed on this form becomes ineligible at any time for the coverage available through the City of Oakland, you will
promptly notify the City of Oakland
DHRM – Risk & Benefits Division
and submit all requested documentation.
All healthcare services provided or benefits paid on behalf of any ineligible employee or dependent are subject to collection by the health plan involved or
by the City of Oakland.
If you elect to waive medical coverage, you must complete a Cafeteria / Medical Waiver Plan Form in addition to this form. Participation in the Waiver
Program applies to an entire plan year. If participation in the Waiver program ends during the plan year and I again become eligible for the Cafeteria Plan
within the same year, you must wait until the next plan year.
The following documentation is required, in addition to a completed Employee Benefits Record Form, for any eligible individual’s enrollment:
REQUIRED ELIGIBILITY DOCUMENTATION
Marriage
Partner
Of
Birth
Adoption
Court
Tax
Medical
PERS
Economically Dependent Child
REQUIRED DOUCUMENTS TO CANCEL BENEFITS FOR SPOUSE/DOMESTIC PARTNER
Dissolution
of Marriage
Domestic
Partner
Rev. 09.Jan.2018