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Benefits Forms and Guidelines
Last Updated July 15, 2008
Benefit Programs Overview
Health & Dental Plans
Vision Plan
COBRA
HCRA/DCRA
Beneficiary Designation
Tax Sheltered Annuities
Retirement
Quick Reference Guide
Benefit Programs Overview New!
This comprehensive resource summarizes the benefits package offered to eligible Cal Poly State University employees. The Powerpoint slide show includes eligibility rules, effective dates, premium costs and instructions regarding enrollment. A great tool for new hires and a helpful review for current employees!
Benefit Programs Overview [ppt] rev. 1/08
Health & Dental Plans
- 2008 Health/Dental Benefits Enrollment/Change Form [pdf fill-in] and companion document, PERS Declaration of Health Coverage [pdf fill-in]
Use for:
- Newly Eligible Enrollment
- Adoption/Birth
- Marriage
- Divorce
- Adding/Deleting Dependents
- Open Enrollment changes
- Health Plan Rates for 2008 [pdf]
- 2008 Health Plan Comparison Chart [pdf] rev. 1/08
- Domestic Partner Tax Dependent Certification [pdf] rev. 12/04
- Guideline for determining lecturer eligibility [word] rev. 7/07
- For instructions on downloading a complete provider list for the PPO plans, click here.
- For intructions on downloading a complete provider list for the Blue Shield HMO plan, click here.
Vision Plan
(VSP)
- For the list of doctors as of July, 2006, click here.
- Out of Network Reimbursement [pdf] rev. 1/07
- Video Display Terminal Claim Form (for employees working on computer 4 or more hours per day) [pdf] rev. 1/07
COBRA
HCRA/DCRA
(Health Care and Dependent Care Reimbursement Accounts)
- What is a Flexible Spending Account? [pdf] rev. 9/07
- HCRA Quick Facts Brochure with Example Scenarios [pdf] rev. 9/07
- HCRA Detailed Brochure [pdf] rev. 9/07
- DCRA Detailed Brochure [pdf] rev. 9/07
- HCRA/DCRA Enrollment form for 2008 calendar year enrollment [pdf] rev. 1/08
- HCRA/DCRA Claim forms (word) (pdf)
Beneficiary Designation
- Changing Your Beneficiary Checklist [pdf]
Tax Sheltered Annuities (TSA)
Retirement
- Timelines and Information about The Retirement Process rev. 6/08
- CalPERS Service Credit Cost Calculator - Step by Step Guide [pdf] rev. 4/06
- Instructions and Form for Requesting Additional Retirement Service Credit (ARSC) [pdf]
- Check Service Credit purchase status online [word]
- Separating From Employment (redirects to Separation/Retirement page)
- Employment after Retirement [pdf] rev. 2/07
Quick Reference Guide [pdf] rev. 1/08
(Includes web sites, phone numbers and FAQ's relating to benefits)
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