Benefits Forms
DentalDelta Dental MetLife Life Insurance Hartford Hartford Life Insurance Enrollment Form (PDF) - Flexible Spending Account
- Dependent Care Account
- FSA Eligible Expenses List (External Link)
- Schedule your virtual meeting with American Fidelity to enoll and/or obtain plan information.
CalSTRS
To obtain more information regarding your retirement plan, you can call and/or visit their website:
1(800) 228-5453
CalPERS To obtain more information regarding your retirement plan, you can call and/or visit their website:
1(888)225-7377
- Fringe Benefit Consortium (FBC) Information (External Link)
- TSA Online Enrollment Instructions
- 403(b) Salary Reduction Agreement (PDF)
- 457 Salary Reduction Agreement (PDF)
- Universal Availability Notice - 403B/457 Plans (PDF)
For inquiries and/or enrollment, please reach out to the following email address and phone number:
FBCsupport@planmember.com Or call 1-833-752-6322
Voluntary Plan Changes and Enrollments:
At this time, changes and/or enrollment options for voluntary plans will not be available through Self-Service. Click on Voluntary Plans for instructions on how to enroll or make changes.To cancel your voluntary benefits, you must fill out the Universal Termination Form and indicate the name of the plan you want to terminate. Upload the universal termiantion form to the Document Dropbox for Human Resources, under document type, select Benefits.
Cancer Care Plans
AFLAC - AFLAC Cancer Overview
- Schedule your virtual meeting with AFLAC to enroll and/or obtain plan information.
AFLAC Representative: Catherine Gohl
P: (858) 429-5425
Email: catherine_gohl@us.aflac.com
American Fidelity American Fidelity Representative: Dmitri Kabantsev
Email: dmitri.kabantsev@americanfidelity.com
Pacific Educators - Pacific Educators Cancer Coverage Plan Information and Enrollment Form.
- To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document type, select Benefits.
To obtain plan information, please contact Customer Service at
P: (800) 722-3365
Website: www.peinsurance.com
Accident/ Hospital/Illness/Sick AFLAC - AFLAC Hospital Overview
- Schedule your virtual meeting with AFLAC to enroll and/or obtain plan information.
AFLAC Representative: Catherine Gohl
P: (858) 429-5425
Email: cateherine_gohl@us.aflac.com
Disability Income Insurance AFLAC - AFLAC Short-Term Disability Overview
- Schedule your virtual meeting with AFLAC to enroll and/or obtain plan information.
AFLAC Representative: Catherine Gohl
P: (858) 429-5425
Email: catherine_gohl@us.aflac.com
American Fidelity American Fidelity Representative: Dmitri Kabantsev
CSCP- Pacific Educators - Pacific Educators Group Disability Income Insurance Plan and Enrollment Form
- To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document type, select Benefits.
To obtain plan information, please contact Customer Service at
P: (800) 722-3365
Website: www.pensurance.com
Accidental Death & Dismemberment Insurance MetLife - To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document type, select Benefits.
Life Insurance American Fidelity American Fidelity Representative: Dmitri Kabantsev
Hartford Supplemental - To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document type, select Benefits.
- Hartford Supplemental Life Insurance 10 months
- Hartford Supplemental Life Insurance 12 months
MetLife - To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document ype, select Benefits.
- MetLife Voluntary Life Insurance Enrollment Kit 10 months (PDF)
- MetLife Voluntary Life Insuarnce Enrollment Kit 12 months (PDF)
- MetLife Statement of Health (PDF)
- MetLife Certificate of Insurance (PDF)
- MetLife Beneficiary Designation Form
Pacific Educators - To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document type, select Benefits.
- Pacific Educators Voluntary Group Term Life Insurance Enrollment Form
To obtain plan information, please contact Customer Service at
P: (800) 722-335
Website: www.peinsurance.com
Long Term Care UNUM To enroll and/or obtain coverage information visit:
Website: www.unuminfo.com/consortium
MetlIfe Legal Service Benefit Program MetLife - To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document type, select Benefits.
- Coverage Overview
To enroll please fill out attached enrollment form.
10thly Employees Enrollment Form
12th Employees Enrollment Form
Pet Insurance Information MetLife (This benefit is direct through MetLife, including payment. There are no payroll deductions for this plan.)
- Southwestern College Employees can obtain membership through JAWS. For additional informaton Click Here.