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.
Forms
- VSP Computer Vision Care Form (PDF)
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 Continuous Coverage Form (PDF)
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 (PDF)
Submit your receipts for health and dependent care reimbursement to ASI using this form. - HCRA Debit Card Request Form (PDF)
Savings
- TSA Catch-Up Plan Maximum Contribution Worksheet(opens in new window)
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. Opens in Box must download to complete form.
Life Insurance Beneficiary Change Form
- The California State University Beneficiary designation/Change (PDF)
For both Employer-paid and Volunteer beneficiary changes
CalPERS Forms
- CalPERS Affidavit of Parent/Child Relationship (PDF)
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 (PDF)
If you have a disabled dependent, send the completed form to CalPERS. Also send a CalPERS Medical Report for the Disabled Dependent Benefit Form (PDF) if this is the initial submission. CalPERS will periodically request that you update this information. - CalPERS Pre-Retirement Lump Sum Beneficiary Designation (PDF)
If you are a CalPERS member, use this form to establish or change a beneficiary. Send the form directly to CalPERS.