Forms

Mary Hao, Director, Human Resources

Choose one or more categories below:

Benefits

Form NameTypeIDFiling Fee
2017 Benefits Guide for Eligible Contingent-Hire EmployeesOnline Form $0
2017 Benefits Guide for Regular HiresPDF $0
2018 Employee Benefits Guide for Eligible Contingent-Hire EmployeesPDF $0
2018 Employee Benefits Guide for Eligible Regular-HirePDF $0
Anthem Blue Cross PPO - 2018 Summary of Benefits and Coverages (SBCs)PDF $0
Anthem Blue Cross PPO - Evidence of CoveragePDF $0
Anthem Blue Cross PPO 2017 Benefit SummaryPDFGroup No.1836 JB$0
Anthem Blue Cross PPO Enrollment FormPDF $0
Connect Your Care Claims Made EasyPDF $0
ConnectYourCare Brochure Flexible Spending Account PDF 0
ConnectYourCare Enrollment Form Flexible Spending AccountPDF 0
ConnectYourCare Enrollment Guide Flexible Spending AccountPDF 0
ConnectYourCare Flexible Spending Account Election CalculatorExcel Spreadsheet $0
ConnectYourCare Transit Plan OverviewPDF 0
Delta Dental Benefits OverviewPDFGroup No. 1909$0
Delta Dental Enrollment and Change FormPDFGroup No. 1909$0
Glossary of Health Coverage and Medical TermsPDF $0
Hartford Beneficiary Add/Change FormPDF $0
Hartford Evidence of CoveragePDF $0
Hartford Life/LTD Benefit SummaryPDF $0
Hartford Life/LTD Benefit Summary - Deputy Probation Officers, Probation Managers and Juvenile Corrections OfficersPDF $0
Hartford Life/LTD Enrollment FormPDF $0
Hartford Life/LTD Enrollment Form – Deputy Probations Officers, Probation Managers and Juvenile Corrections OfficersPDF $0
Kaiser Enrollment / Change Form for 2017PDF $0
Kaiser Evidence of Coverage HDHP for Contingent HiresPDF $0
Kaiser Evidence of Coverage Plan LPDF $0
Kaiser Evidence of Coverage Plan SPDF $0
Kaiser HDHP for Extra-Hires - 2017 Summary of Benefits & CoveragesPDF $0
Kaiser Plan HDHP - 2018 Summary of Benefits & Coverages (SBCS)PDF $0
Kaiser Plan L - 2017 Summary of Benefits & CoveragesPDF $0
Kaiser Plan L - 2018 Summary of Benefits & Coverages (SBCS)PDF $0
Kaiser Plan S - 2017 Summary of Benefits & CoveragesPDF $0
Kaiser Plan S - 2018 Summary of Benefits & Coverages (SBCS)PDF $0
Vision VSP 2016 Evidence of CoveragePDFGroup No. 00-1098030
Vision VSP Enrollment and Change FormPDF $0
Vision VSP Overview of BenefitsPDF 0
Voya Life and LTD Beneficiary Designation FormPDF 0
Voya Life and LTD Drop Coverage FormPDF $0
Voya Life and LTD Evidence of Insurability ApplicationPDF 0
Voya Life and LTD Evidence of Inusurability InstructionsPDF 0
Voya Life Insurance Evidence of CoveragePDF 0
Voya Long Term Disability Evidence of CoveragePDF 0
Waiver of Dependent Dental and Vision CoveragePDF $0
Waiver of Participation in Medical CoveragePDF $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

General Forms

Form NameTypeIDFiling Fee
Anthem Blue Cross PPO 2018 SummaryOnline Form $0