Forms

Friday, November 20, 2009

Affidavit of Marriage (County)

Affidavit of Marriage (CalPERS)

Affidavit of Eligibility for Economically Dependent (CalPERS)

Declaration of Tax Dependent Status

Deferred Compensation Change Form

Nationwide Asset Transfer Out Request

Nationwide Beneficiary Change Form

Nationwide Distribution Request Form

Nationwide Incoming Assets Form

Nationwide Unforeseeable Emergency Distribution Application

VALIC Administrative Change Form

VALIC Unforeseeable Emergency Withdrawal Form

VALIC Distribution Request Form

VALIC Transfer In/Rollover Form

VALIC Intra Plan Transfer Out

VALIC Beneficiary Designation Form

Standard Long Term Disability Claim Package

Standard Life Long Term Disability (LTD) Certificate

Sedgewick/VPA Disability Forms

Dependent Care Claim Form

Health Claim Form

Health Care Letter of Medical Necessity (LMN)

Health Care Capital Expense Worksheet

Notification of Retirement - Intent to Use Leave Accruals

Employee Status Change Form

Password Security

Beneficiary Designation to Receive Warrant

Leave Balance Cash Out (Management, Confidential, Unrepresented)

Leave Balance Cash-Out (LIUNA and SEIU Only)

Annual Leave Buy-Down Request (Management, Confidential, Unrepresented employees

2010 Retiree Annual Enrollment Guide

2010 Retiree Benefit Election Form

Additional Forms/Current Retirees Page

Request to Cancel Health Care Benefits Form

2010 Active Employee Annual Enrollment Guide (Full Version)

2010 Active Employee Annual Enrollment Mini-Guide

2010 Active Employee Benefit Election Form (County Plans)

2009 Active Employee Benefits Enrollment Guide

2009 Active Employee Benefit Election Form (County Plans)

Statement of Financial Liability for Domestic Partner Health Benefits

Medical Report for Disabled Dependent Benefits (County Plans

Member Questionnaire for Disabled Dependent Benefits (County Plans)

Domestic Partner - Declaration of Dependent Tax Status

Affidavit of Marriage (County Plans)

2010 Active Employee Annual Enrollment Guide (Full Version)

CalPERS 2010 Annual Enrollment Website

2010 Active Employee Annual Enrollment Mini-Guide

2010 Active Employee Benefit Election Form (CalPERS Plans)

Health Plan Enrollment Form HBD-12 (CalPERS Plans)

2009 Active Employee Benefit Election Form (CalPERS Plans)

2009 Active Employee Benefits Enrollment Guide

Affidavit of Marriage (CalPERS)

Affidavit of Eligibility for Economically Dependent (CalPERS)

Statement of Financial Liability for Domestic Partner Health Benefits

Medical Report for Disabled Dependent Benefits (CalPERS Plans)

Member Questionniare for Disabled Dependent Benefits

Zip Code Election (HBD109) (CalPERS Plans)

Leave Forms
	Leave forms are located in the HR Toolbox at www.WorkforceExchange.net.

Lincoln Financial Life Insurance

Lincoln Financial Basic Life Insurance Certificate (All SEIU & LIUNA employees have this coverage, paid for by the County.)
Lincoln Financial Beneficiary Designation Form
Lincoln Financial Enrollment Form for Group Insurance
Lincoln Financial Evidence of Insurability
Lincoln Financial Life Insurance Claim Form
Lincoln Financial BeneficiaryConnect Services
Lincoln Financial Supplemental Life Insurance Certificate (Employees who elect this coverage; it is voluntary, and 100% paid for by employee.)
Lincoln Financial Portability/Conversion Summary
Lincoln Financial Conversion Form
Lincoln Financial Portability Form
Lincoln Financial TravelConnect Services

Standard Life Insurance

Standard Life Insurance Beneficiary Form
Standard Life Insurance Certificate (Management, Confidential, Unrepresented, Elected Officials, DDAA, LEMU and RSA Public Safety)
Standard Life Insurance Claim Form
Standard Life Insurance Evidence of Insurability
Standard Supplemental (Additional) Life Benefits Summary
Standard Supplemental Life Enrollment Form
Standard Life Portability Application
Standard Life Conversion Application
Standard Request for Conversion Material
Standard Frequently Asked Questions About Basic Life Benefits
Standard Frequently Asked Questions About Long Term Disability (LTD) Benefits

MGMT -Notification of Retirement - Intent to Use Leave Accruals

SEIU Notification of Retirement - Intent to Use Leave Accruals

Spouse/Dependent Information Form

CalPERS Beneficiary Designation Form

Post Employment Program Election Form (LIUNA and SEIU Only)

Post Employment Program Election Form (Mgmt, Conf, Unrep, DDAA and LEMU Only)

VEBA Systematic Payment Form

VEBA Claim Form

2010 Retiree Benefits Enrollment Guide

2010 Retiree Benefit Election Form

Medical/Health Benefits Forms

Retiree Change Form

Enrollment/Change Form

Reimbursement Claim Form

Medical Eye Services Claim Form