Human Resources Service Center

Benefit Forms

Many of these forms open in Box.  Once opened in Box you must download the form then select Enable All Features to complete form.

Health Forms

DCRA/HCRA Forms

  • DCRA/HCRA Manual Claim Form (PDF)
    Submit your receipts for health and dependent care reimbursement to ASI using this form.
  • HCRA Debit Card Request Form (PDF)
    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

Life Insurance Beneficiary Change Form

CalPERS Forms