Forms

Mary Hao, Director, Human Resources

Choose one or more categories below:

Benefits

Form NameTypeIDFiling Fee
"Coming Soon" Anthem Blue Cross PPO - Evidence of Coverage for 2017PDF $0
2016 Open Enrollment Flyer for Extra Hire EmployeesPDF 0
2017 Health Benefits Guide - Eligible Extra-Hire EmployeesOnline Form $0
2017 Health Benefits Guide - Regular HiresPDF $0
Anthem Blue Cross 2017 Summary of Benefits and CoveragesPDFGroup No.1836 JB$0
Anthem Blue Cross Medical Enrollment FormPDF $0
Anthem Blue Cross PPO Enrollment Form for 2017PDF $0
Connect Your Care Claims Made EasyPDF $0
Delta Dental Enrollment FormPDFGroup No. 1909$0
Delta Dental Overview of BenefitsPDF $0
Flexible Spending Account ConnectYourCare BrochurePDF 0
Flexible Spending Account ConnectYourCare Enrollment FormPDF 0
Flexible Spending Account ConnectYourCare Enrollment GuidePDF 0
Flexible Spending Account Election CalculatorExcel Spreadsheet $0
Glossary of Health Coverage and Medical TermsPDF $0
Kaiser 2017 Evidence of Coverage – HDHP for Extra HiresPDF $0
Kaiser 2017 Evidence of Coverage EOC Plan LPDF $0
Kaiser 2017 Evidence of Coverage EOC Plan SPDF $0
Kaiser Enrollment / Change Form for 2017PDF $0
Kaiser HDHP for Extra-Hires - 2017 Summary of Benefits & CoveragesPDF $0
Kaiser Plan L - 2017 Summary of Benefits & CoveragesPDF $0
Kaiser Plan S - 2017 Summary of Benefits & CoveragesPDF $0
Life Insurance Voya Evidence of CoveragePDF 0
Life LTD Drop Coverage FormPDF $0
Life LTD Evidence of Inusurability InstructionsPDF 0
Life LTD Voya Beneficiary Designation FormPDF 0
Life LTD Voya Evidence of InsurabilityPDF 0
Long Term Disability Voya Evidence of CoveragePDF 0
Transit Plan ConnectYourCare OverviewPDF 0
Vision Enrollment and Change FormPDF $0
Vision VSP 2016 Evidence of CoveragePDFGroup No. 00-1098030
Vision VSP 2016 Overview of BenefitsPDFGroup No. 00-1098030
Vision VSP Overview of BenefitsPDF 0
Waiver of Dependent Dental and Vision CoveragePDF $0
Waiver of Participation in MedicalPDF $0

Classification and Salary

Employee Labor Relations

Form NameTypeIDFiling Fee
Authorization to Release Medical InformationPDFPMR 46 - Form 1$0
Catastrophic Leave ApplicationPDFPMR 44 - Form 3$0
Catastrophic Leave DonationPDFPMR 44 - Form 4$0
Complaint FormPDFPMR 21 - Form 1$0
Consent to Release Employment InformationPDFPMR 46 - Form 2$0
Discrimination Appeal FormPDFPMR 21 - Form 1$0
Employee Accident/Injury/Illness Investigation ReportPDFPMR 42 - Form 1$0
Employee Electronic Media Agreement and ApplicationPDFPMR 23 - Form 1$0
Employee GrievancePDFPMR 24 - Form 1$0
Employee Performance Evaluation ReportPDFPMR 43 - Form 1$0
Employee Reasonable Accommodation RequestPDFPMR 49 - Form 1$0
Employees Serious Health Condition - Physician or Practitioner Certification FormPDFPMR 44 - Form 2A$0
Examination AppealPDFPMR 31 - Form 2$0
Family Member Serious Health Condition - Physician or Practitioner Certification FormPDFPMR 44 - Form 2B$0
Fitness for Duty to Return from Leave CertificationPDF PMR 44 - Form 1$0
Performance Planning and Review Form for Managers and SupervisorsPDFPMR 43 - Form 2$0
Personnel RequisitionPDFPMR 30 - Form 1$0
Promotion Without Examination RequestPDFPMR 31 - Form 1$0
Report of Hazard or Unsafe Condition FormPDFPMR 26 - Form 2$0
Request for Family/Medical Leave FormPDFPMR 44 - Form 2$0
Request to Engage in Supplemental EmploymentPDFPMR 20 - Form 1$0
Telework Agreement FormPDFPMR 27 - Form 1$0
Workplace Security and Safety Incident Investigation ReportPDFPMR 26 - Form 1$0

Employment Opportunities

Form NameTypeIDFiling Fee
Employment ApplicationPDF $0

Equal Employment