Office of Human Resources

Benefit

Carrier

Evidence of Coverage (EOC)

Universal

Enrollment

Required Form

Health

Anthem Blue Cross California Care

• High HMO $10

• Low HMO $30

Anthem Blue Cross PPO

Kaiser Permanente Health HMO

• High HMO $5
• Low HMO $20

• High HMO $10 (pending)

• Low HMO $30

• PPO

• High HMO $5
• Low HMO $20

• medical document

• Rx document

• medical document
• Rx document

• medical document
• Rx document

• High HMO $5
• Low HMO $20

Dental

Delta Dental of California

• Standard
• Enhanced

• Standard
• Enhanced

• Standard
• Enhanced

Vision

Vision Service Plan

VSP Claim Form

• VSP EOC

• VSP Summary

Life

Anthem Blue Cross Life Insurance

Life Insurance Enrollment Form

• Anthem Blue Cross Life Insurance

LTD

Fort Dearborn Life Insurance Company

(Long Term Disability)

LTD Insurance Enrollment Form

• LTD Benefit Booklet

Flexible

Spending

Account

Employee Benefits Specialist - EBS

• Medical Spending Account - $2,500 Per Year
• Dependent Care Spending Account - $5,000 Per Year

FSA Claim Form

FSA Dependent Care Assistance Plan

FSA Direct Deposit Form

Employee Assistance

Plan

Concern EAP

Company Code: Chabot Las Positas

Supplemental Life

Anthem Blue Cross Life Insurance Company

• Supplemental Enrollment Form
• Anthem Optional Life Information Sheet and Rate Calculations
• (Supplemental and Dependent Life insurance is available through payroll deduction.)

Salary Reduction Plans

Envoy / Plan Services

403(b) & 457

403b/TSA Enrollment Form

The District's 403b Administrators

Updating or establishing PERS account, need to fill out next two forms:

• CalPERs 457 Employee Action Form & Procedures
• Envoy Salary Reduction Agreement 457 Plan Form

Questions?  Please contact Payroll at (925) 485-5228 or Benefits at (925) 485-5504.

• Pre-tax retirement savings on a voluntary basis.

Workers' Compensation

Coverage for work related injury/illness.

Supervisor Instructions

Supervisor Report of Injury

Approved Occupational Health Clinic Providers

Workers' Compensation ( DWC1) Claim Form

TSA In Lieu

of Medical Plan

Domestic

Partner

Benefits

Certificated: To include those individuals who meet the requirements for domestic partnership which are set forth in CA Family Code Section 297 and the CLPCCD - CLPFA Bargaining Agreement, Article 20.A.3.

Classified: Benefits for same and opposite gender partners with proper documentation and meet the requirements which are set forth in CA Family Code, Section 297, CLPCCD Board Policy and CLPCCD S.E.I.U 1021 Bargaining Agreement, Article 16.