Fillable Get File Group Id 4202574 (California Maritime Academy)

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Get File Group Id 4202574 (California Maritime Academy)

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BENEFITS ENROLLMENT/CHANGE WORKSHEET
PLEASE COMPLETE AND SUBMIT THIS FORM TO THE DEPARTMENT OF HUMAN RESOURCES WITHIN 60 DAYS OF YOUR APPOINTMENT DATE.
EMPLOYEE INFORMATION (Please Print)
Name (First, M, Last): ____________________________________Social Security Number: __________________________
Mailing Address: ______________________________________________________________________________________
Phone Number: _________________________________ Date of Birth__________ Gender ☐ Female ☐ Male
Marital Status: ☐ Single ☐ Married ☐ Domestic Partnership Date of Marriage/DP: _______________________________
Hire Date: _____________ Department: ____________________ Position: _______________________________________
PLEASE ANSWER ALL OF THE FOLLOWING:
Are you transferring from a CalPERS/State Agency? ☐ No ☐ Yes, Agency ________________________________________
Are you currently working at another CalPERS/State/Public Agency? ☐ No ☐ Yes Agency___________________________
If YES, it is YOUR responsibility to notify the Department of Human Resources should you retire from that Agency (Please
Initial) __________
Are you a CalPERS Retiree? ☐ No ☐ Yes
NEW ENROLLMENT SELECTIONS (Health and Dental Coverage):
☐ I elect to enroll in the following health plan:
☐Anthem Blue Cross Select ☐ Anthem Blue Cross Traditional ☐ Blue Shield Access☐ Health Net SmartCare
☐ Kaiser ☐United HealthCare ☐ Western Health Advantage ☐PERS Care ☐PERS Choice ☐ PERS Select
☐ Police Officers Research Association of California (PORAC) PPO ☐ Sharp Health Plan (available only in So. Cal)
☐ I elect to enroll in the following dental plan:
☐ Delta Dental (PPO) ☐ Delta Care USA (HMO)
☐ I elect to enroll in the FlexCash* option for ☐ Health ☐ Dental
Alternate Insurance Coverage: Subscriber’s Social Security Number: ___________________________________________
Medical Insurance Company: ________________________________________Group Number: ______________________
Dental Insurance Company: _________________________________________Group Number: ______________________
Is your spouse currently employed by a CSU? ☐ No ☐ Yes, CSU: _______________________
*If electing FlexCash, you must provide proof of coverage.
PLEASE TURN OVER
BENEFITS ENROLLMENT/CHANGE WORKSHEET
DEPENDENT INFORMATION (Please Print)
Please list all dependents you wish to have covered under the appropriate sections below. Please check the
appropriate benefit coverage you are electing for each dependent (medical, dental, vision).
☐ Spouse or ☐ Domestic Partner
*If enrolling a spouse, a copy of the marriage certificate is required
**If enrolling a Domestic Partner, a copy of the Declaration of Domestic Partnership is required. Review the Domestic Partner’s
Benefits Tax Implication handout.
Name (First, M, Last): ________________________________ Birth Date: ________________ Gender: ☐ Female ☐ Male
Social Security Number: _______________________
Please enroll in ☐ Medical ☐ Dental
If you are currently being covered as a dependent under another CalPERS sponsored health plan and/or State covered dental plan,
you and/or your family members cannot also be covered under the CSU health and dental plan(s).
PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS:
1. Is your Spouse/DP currently on a medical/dental plan through a CalPERS/State agency? ☐ No ☐ Yes
If yes, please list the agency your spouse is working for: __________________________________________
2. If yes, are you/your dependent(s) currently enrolled in your Spouse’s/DP’s plan? ☐ No ☐ Yes
3. Are you and your dependent(s) being deleted from this coverage? ☐ No ☐ Yes, Effective Date ______________
DEPENDENTS (Children under the age of 26 years)
*A copy of the birth certificate and Social Security Number is required when enrolling dependent children
Family
Relationship
Legal Name
(First, M, Last)
DOB
(mm/dd/yy)
Social Security
Number
Gender
(M/F)
Dental
Add Delete
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ I elect to ENROLL or CHANGE to the Health Benefits Plan as shown on page 1 and authorize deductions to be made from my
salary to cover my share of the monthly premium as it is now or as it may be in the future. I also certify that the names of all the
dependents listed above are eligible family members as defined in the Public Employees’ Medical and Hospital Care Act
☐ I elect to CANCEL my Health Benefits Plan as shown on page 1
☐ I DO NOT wish to enroll in the Health Benefits Plan under the Public Employees’ Medical and Hospital Care Act
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Get File Group Id 4202574 (California Maritime Academy)

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Completed 16 July 2020

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