Fillable Employee-Benefits-Record-Form CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM

Fill Online, Printable, Fillable, Blank Employee-Benefits-Record-Form CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM Form

Use Fill to complete blank online CITY OF OAKLAND (CA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Employee-Benefits-Record-Form CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM

On average this form takes 20 minutes to complete

The Employee-Benefits-Record-Form CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM form is 1 page long and contains:

  • 0 signatures
  • 51 check-boxes
  • 57 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Oakland

BROWSE CITY OF OAKLAND (CA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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
New Hire
Rehire / Reinstatement
Birth / Adoption
Marriage / New Domestic Partnership / Divorce
Open Enrollment
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 HEALTH PLAN
*You must live in a covered service area to enroll in these plans. Please refer to the CalPERS Health Benefit Summary publication
to confirm service areas or visit http://www.calpers.ca.gov.
PERS Choice PPO**
PORAC (Sworn Police)
Waive Medical Coverage
(OPOA are not eligible)
Blue Shield Access
Western Health Advantage
PERS Select PPO**
United Healthcare
PERS Care PPO**
Designate Physician:
HealthNet SmartCare HMO*
** Administered by Anthem BlueCross
CHOOSE YOUR DENTAL PLAN NON-SWORN ONLY *
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
LIFE INSURANCE (NON-SWORN EMPLOYEES ONLY)
I appoint as revocable beneficiary(-ies) of insurance payable
in the event of my death:
Name
Relationship
% of Benefit
(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
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
EBR
Marriage
Cert.
Domestic
Partner
Cert.
Non-Tax
Of
Benefits
Birth
Cert.
Adoption
Cert.
Court
Order
Tax
Returns
Medical
Evidence
PERS
Affidavit
Employee
Spouse
Domestic Partner
Natural Child
Step Child
Domestic Partner Child
Adopted Child
Child Legal Guardianship
Economically Dependent Child
Disabled Child
Court Order Child
REQUIRED DOUCUMENTS TO CANCEL BENEFITS FOR SPOUSE/DOMESTIC PARTNER
EBR
Dissolution
of Marriage
Certificate
Dissolution
Domestic
Partner
Certificate
Employee
Spouse
Domestic Partner
Rev. 09.Jan.2018
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Employee-Benefits-Record-Form CITY OF OAKLAND EMPLOYEE BENEFITS RECORD FORM

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document