Forms
You will need Adobe Acrobat Reader to access PDF forms. If you do not have this software, it can be download for free from the link provided.
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
