Forms
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To open each form, click on the link you wish to open. To save files, right-click on the icon of the format and select Save Target As..., find your location and select Save.
Benefit Forms
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- Additions & Deletions Worksheet - To add/ change/ delete health and/or dental coverage for the employee and/or dependents.
- Affidavit of Marriage
- Beneficiary Form - CalPERS - CalPERS members only
- Beneficiary Form - Standard Insurance - Life and AD&D Insurance
- Claim Form - Anthem Blue Cross - PersSELECT/ PersCHOICE/ PersCARE medical claim reimbursement
- Claim Form - Mail Order Prescriptions - To enroll or refill PersCHOICE/ PersCARE Prescriptions by mail order
- Claim Form - Prescription Drugs - PersCHOICE/ PersCARE Prescription claim reimbursement
- Claim Form - Delta Dental - Dental claim reimbursement
- Declaration of Health Coverage
- Dental Enrollment Form
- DP Certificate of Domestic Partnership - Domestic Partner registration with the State
- DP Statement of Financial Liability - For Domestic Partners adding dependents to benefits
- DP Dependent Certification - For Domestic Partners adding dependents to benefits
- Fee Waiver Employee Application - For employees
- Fee Waiver Dependent Application - For dependents
- Fee Waiver Career Development Plan - If seeking a degree, to accompany initial employee fee waiver application
- Fee Waiver Career Development Plan Update - If you have a Career Development Plan on file, to accompany every employee fee waiver as an update to the original
- Fee Waiver/ Non-Matric Employee Application Form - If not seeking a degree, to accompany the employee fee waiver application
- FlexCash Enrollment Form
- Health Care/Dependent Care Enrollment Form - 2013 - HCRA/ DCRA Enrollment Form-2013
- Health Care/Dependent Care Reimbursement Form - HCRA/ DCRA Reimbursement Form
- Health Care (HCRA) Debit Card Enrollment Form - An 'opt in' benefit that can accompany a HCRA enrollment - effective 2012
- Leave of Absence Form - Staff medical, military or personal leave and faculty medical leave
- New Employee Benefits Enrollment Worksheet - New employee enrollments
- Open Enrollment Worksheet- Health only
- Physician's Certification for Medical Leave
- Vision Claim Form-VSP - Out of network claim reimbursements
- Vision Video Display Terminal Form (VDT Form)- VSP
Workers' Compensation Forms
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Staff Forms
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- Applicant Authorization & Release Form
- Background Check Form
- Employee Data Sheet Form
- Evaluation - MPP Evaluation Form *Revised*
- Evaluation - Procedures Represented and Confidential *Revised*
- Evaluation - Quick Reference List
- Evaluation - Represented & Confidential Evaluation Form
- Evaluation - Self-Appraisal Form
- Evaluation - Unit 4 Appraisal Form
- Job Action Form
- Job Description Template - Instructions for Job Descriptions w/Action Verbs & Skills
- Manpower Requisition Form
- Position Review Request - Instructions for Position-Comp Review
- In-Range Progression Request Form
- Pre-Employment Verification Form
- Reconsideration Procedure Form A - CSUMB Reconsideration Procedure/Non-Represented
- Request to Recruit
- Resignation Form
- Selected Candidate Narrative Form
- Special Consultant Agreement
- Volunteer Form
- Work Schedule Designation Form
100 Campus Center
