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

  • Benefits Enrollment/Change Worksheet (PDF)
    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 (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)
    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