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Benefits Forms

Health Forms

Benefits Enrollment/Change Worksheet
Used to enroll in a plan(s), add or delete dependents with a qualifying event, or to make changes during the annual open enrollment period.

VSP Computer Vision Care Form
CSU employees are eligible for Computer Vision Care glasses every other year. Complete this form and give it to your vision care provider at your appointment. (Prescription must be different than regular eyewear prescription)

Orthodontic Takeover Form
New members (or their dependents) of the DeltaCare USA prepaid dental program may be eligible to continue their current orthodontic treatment. Complete this form and send it to the address on the form.

DCRA/HCRA Forms

DCRA/HCRA Manual Claim Form
Submit your receipts for health and dependent care reimbursement to ASI using this form.

HCRA Debit Card Request Form
Complete and send this form to request a Visa debit card for health care expenses. Of note; there is a $1.00 per month ($12.00 per year) administrative fee that is deducted from your initial HCRA contribution.

Savings

TSA Catch-Up Plan Maximum Contribution Worksheet
Employees may be eligible for the 15-year and/or Age 50 Catch-Up. To determine eligibility, complete this form and submit to the Benefits Office. Determination is made by the CSU Chancellor’s Office.

Life Insurance Forms

Employer-Paid Life and AD&D Beneficiary Designation/Change Form
Employees who are covered under an employer-paid plan (based on bargaining unit) should use this form to establish or change their beneficiary.

Voluntary Life Insurance Beneficiary Designation/Change Form
This form is used by employees who have purchased a voluntary life insurance policy to establish or change a beneficiary. Send the form directly to the address noted on the form.

CalPERS Forms

CalPERS Affidavit of Parent/Child Relationship
Employees are eligible to enroll family members in benefits programs if a “parent-child relationship” is established with a child who is not your adopted, step, or recognized natural child and specific criteria is met. Complete and send this form directly to CalPERS. You will be required to update this information on an annual basis.

CalPERS Member Questionnaire for Disabled Dependent Benefit Form
If you have a disabled dependent, send the completed form to CalPERS. Also send a CalPERS Medical Report for the Disabled Dependent Benefit Form if this is the initial submission. CalPERS will periodically request that you update this information.

CalPERS Pre-Retirement Lump Sum Beneficiary Designation
If you are a CalPERS member, use this form to establish or change a beneficiary. Send the form directly to CalPERS.

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