Human Resource Services

Benefit

Carrier

Health

Blue Cross California Care HMO

Blue Cross PPO

Kaiser Permanente Health HMO

Universal Enrollment Form

Dental

Delta Dental of California

Universal Enrollment Form

Vision

Vision Service Plan

Universal Enrollment Form

VSP Claim Form

Life*

Fort Dearborn Life Insurance Company

Life Insurance Enrollment Form (Fort Dearborne Life)

LTD*

Fort Dearborn Life Insurance Company (Long Term Disability)

Life Insurance Enrollment Form (Fort Dearborne Life)

Flexible Spending Account*

Employee Benefits Specialist – EBS

• Medical Spending Account - $3,000 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

Reliance Insurance

• (Supplemental and Dependent Life insurance is available through payroll deduction.)

Salary Reduction Plans*

403(b) & 457

403b/TSA Enrollment Form

403b/TSA List of Vendors revised 2/27/08

457 Employee Action Form

• Pre-tax retirement savings on a voluntary basis.

Workers' Compensation*

• Coverage for work related injury/illness.

TSA In Lieu of Medical Plan

• Full-time employees electing not to enroll in a medical plan and who provide proof of other medical coverage, may elect to have a $175 Board approved TSA purchased monthly by the District.

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.

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.