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MANAGEMENT
Human Resources

Benefit Forms

Form Description
Affordable Care Act (ACA) Health Insurance Marketplace Employee Notice Notice for employees regarding their health coverage. To be used if shopping for coverage through Covered California.
Benefits Enrollment Worksheet Used to enroll, make changes or cancel Health, Dental or FlexCash elections.  Supporting documentation may also be required. Send completed form to hrbenefits@csusm.edu.
CalPERS Beneficiary Designation Form Used to identify or change a CalPERS Member's beneficiary.  This is managed directly through CalPERS.
CalPERS Dependent Verification Affidavit

CalPERS will mail the Dependent Verification Affidavit to employee directly 90 days prior to the Dependent Verification month.  You may also obtain a copy from your MyCalPERS account during your verification period. Dependent Verification is required every 3 years based on Employee's Birth Month. 

Completed Affidavits and supporting documentation is submitted to hrbenefits@csusm.edu for processing.  Refer to the Dependent Eligibility Verification page.
CalPERS Disabled Dependent Member Questionaire and Medical Report

If you have a Disabled Child who is nearing age 26, or is age 26 or older, and is incapable of self-support, you may be able to continue health and dental coverage by submitting this form and the Authorization to Disclose Protected Health Information form to CalPERS within the required time frame.

For more information, refer to the Disabled Dependents tab on the CalPERS Enroll Family Members webpage.
CalPERS Service Credit Purchase Options

CalPERS website to explain the types of Service Credit Purchase Options available and how to submit a request.  Questions should be directed to CalPERS. 
Catastrophic Leave Donation Form Used to donate vacation or sick accruals to employees in need of extra leave balances due to a catastrophic event.
COBRA Continuation Coverage Provided to eligible employees/dependents who wish to continue their medical coverages after Employer Group Coverage ends. Not available for download.
Dental Enrollment Authorization Form Use the Benefits Enrollment Worksheet to make dental plan enrollments, changes or cancellations. Send completed form to hrbenefits@csusm.edu.
Dependent Care Reimbursement Enrollment Form (DCRA) via AdobeSign

Used to enroll in the Flexible Spending - Dependent Care Reimbursement Account (DCRA) Program for the 2024 Plan Year.  Form is through AdobeSign - Select form name from the WorkFlow Selector Dropdown.
Dependent Care Reimbursement Claim Form (ASIFlex) Used by employee to claim reimbursements under the DCRA Program. Completed form is submitted directly to ASIFlex for processing.
Domestic Partner Tax Dependent Certification Form Send a request to hrbenefits@csusm.edu for information on imputed taxes related to a Domestic Partner being added to your health and/or dental benefits.
Fee Waiver - CSU Application Fee Reimbursement - via AdobeSign Used by eligible employees, spouses, domestic partners, or dependent children who are requesting reimbursement of the CSU Application fee under the provisions of the CSU Tuition Waiver Program.  Form is through AdobeSign - Select form name from the WorkFlow Selector Dropdown.
Fee Waiver - Career Development Form - via AdobeSign Used in conjunction with the Employee Fee Waiver Application when the classes enrolled in are used for Career Development. Form is through AdobeSign - Select form name from the WorkFlow Selector Dropdown.
Fee Waiver - Dependent Application - via AdobeSign Used when Employee wishes to transfer his/her Fee Waiver Benefit to an eligible dependent. Form is through AdobeSign - Select form name from the WorkFlow Selector Dropdown.
Fee Waiver - Employee Application - via AdobeSign Used to enroll in the Tuition Fee Waiver Program. Form is through AdobeSign - Select form name from the WorkFlow Selector Dropdown.
FlexCash Enrollment Authorization Form

Used when an employee has their own health and/or dental coverage (outside of the CSU) and elects to receive cash  in lieu of CSU Health and/or Dental benefits. Send completed form to hrbenefits@csusm.edu.
Health Enrollment Authorization Form Use the Benefits Enrollment Worksheet to make health plan enrollments, changes or cancellations. Send completed form to hrbenefits@csusm.edu.
Health Care Reimbursement Enrollment Form (HCRA) - via AdobeSign

Used to enroll in the Flexible Spending - Health Care Reimbursement Account (HCRA) Program for the 2024 Plan Year.  Form is through AdobeSign - Select form name from the WorkFlow Selector Dropdown.
Health Care Reimbursement Claim Form (ASIFlex) Used by employee to claim reimbursements under the HCRA Program. Completed form is submitted directly to ASIFlex for processing.
Maternity/Paternity/Adoption Paid Leave Application Used by individuals to request paid leave for Maternity, Paternity or Adoption.
Parent Child Relationship Affidavit Used to enroll another person's child (up to age 26) that you have assumed parental status, or assumed parental/economic duties at the time of enrollment and annually there after.  Completed form and supporting documentation is submitted to hrbenefits@csusm.edu for processing.
The Standard - Beneficiary Designation/Change Form Used to identify or change beneficiary information for Employer Paid Life and AD&D insurance, Voluntary Life or Voluntary AD&D insurance.  This is managed directly through The Standard.
TSA/403(b) Catch-Up Plan Maximum Contribution Worksheet Worksheet used for 15 year and/or age 50 Catch Up contribution allowance.  Employees completed form is submitted to the Benefits Office for further handling.
VSP Computer Vision Care (CVC) form For Employees who qualify for the Computer Vision Care (CVC) benefit.  Please contact hrbenefits@csusm.edu to determine benefit eligibility and obtain the CVC Claim Form.  Employees who qualify for the CVC benefit will complete the form and submit to their eye care provider at time of their eye examination.
VSP Premier Enrollment Form Used to voluntarily upgrade their vision coverage for an additional monthly premium amount. Employees must enroll all eligible dependents they wish to maintain vision benefits, as those not included will not be covered under the Basic Plan.  Completed forms are sent to hrbenefits@csusm.edu for processing.
VSP Reimbursement Form To be completed and submitted to VSP when seeking services out-of-network and requesting to be reimbursed for the amount covered under the plan.
VSP Retirement Enrollment Form Used by Retirees who wish to continue Vision Coverage into retirement.