Benefits Forms
Delta Dental
(Dental)MetLife
(Dental)Hartford
(Life Insurance)Hartford Life Insurance Enrollment Form (PDF)
Hartford Certificate of Insurance
- Flexible Spending Account
- Dependent Care Account
- FSA Eligible Expenses List (External Link)
- Schedule your virtual meeting with American Fidelity to enroll and/or obtain plan information.
California Schools VEBA is the District’s third-party administrator for our medical insurance plans and offers employees easy access to health and wellness resources. As VEBA members, employees can take advantage of a variety of programs and services that support their overall well-being.
Medical Plan Side by Side
Comparison And Enrollment form
Kaiser UHC -Find a Doctor VEBA Direct HMO UHC Harmony Plan Alliance 20/30 HMO UHC PPO VEBA Resources
Retirement
To obtain more information regarding your retirement plan, you can call and/or visit their website:
1(800) 228-5453
To obtain more information regarding your retirement plan, you can call and/or visit their website:
1(888) 225-7377
- FBC Model Plan Program Highlights
- Fringe Benefit Consortium (FBC) Plan Member Services
- 403(b) Salary Reduction Agreement
- 457 Salary Reduction Agreement
- Instructions for Updating Contributions Online via SchoolsFirst
- Universal Notification 403b and 457 Plans
- 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 Plans
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 termination form to the ServiceNow Document Dropbox for Human Resources, under document type, select Benefits.
AFLAC - AFLAC Cancer Overview
- Schedule your virtual meetin 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 Schedule your virtual meeting with American Fidelity to enroll and/or obtain plan information.
American Fidelity Representative: Dmitri Kabantsev
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
IMPORTANT: This is a fixed indemnity policy, NOT health insurance.
This fixed indemnity policy may pay you a limited dollar amount if you’re sick or hospitalized. You’re still responsible for paying the cost of your care.
• The payment you get isn’t based on the size of your medical bill.
• There might be a limit on how much the policy will pay each year.
• This policy isn’t a substitute for comprehensive health insurance.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
AMERICAN FIDELITY Schedule your virtual meeting with American Fidelity to enroll and/or obtain plan information.
American Fidelity Representative: Dmitri Kabantsev
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 Schedule your virtual meeting with American Fidelity to enroll and/or obtain plan information.
American Fidelity Representative: Dmitri Kabantsev
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.peinsurance.com
MADISON NATIONAL LIFE To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document type, select Benefits.
Madison National Life AD&D Rate Information
Madison National Life AD&D Enrollment FormNote: Only the ADA section needs to be completed.
AMERICAN FIDELITY Schedule your virtual meeting with American Fidelity to enroll and/or obtain plan information.
American Fidelity Representative: Dmitri Kabantsev
Email: dmitri.kabanstsev@ameicanfidelity.com
HARTFORD SUPPLEMENTAL To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document type, select Benefits.
MADISON NATIONAL LIFE To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document type, select Benefits.
Madison National Life Voluntary Life Insurance Rate Information
Madison National Life Voluntary Life Insurance Enrollment Form
Note: Only the Supplemental Life Insurance section needs to be completed.PACIFIC EDUCATOR 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
To enroll fill out enrollment form and upload to the Document Dropbox for Human Resources, under document type, select Benefits.
To enroll please fill out attached enrollment form.
Coverage Information & How to Enrollment
Frequently Asked Questions & Answers
(This benefit is direct through MetLife, including payment. There are no payroll deductions for this plan.)- Southwestern College Employees can obtain membership information by clicking JAWS.