Benefits Forms for Retirees

Employee benefits forms for current and future Los Rios retirees.

Pre-Retirement Forms

• Resignation Retirement Form P-104
• Retiree Processing Form BS-214

Bank Account

• Authorization for Electronic Transfer Form

Health Insurance Forms

Kaiser

• Kaiser Enrollment/Change Form
• Senior Advantage Enrollment Form

Sutter Health Plus

• Sutter Health Plus Enrollment Form

United Health Care

• Medicare Advantage HMO Enrollment Form
• Medicare Advantage PPO Enrollment Form

Western Health Advantage

• Western Health Advantage Enrollment Form

Delta Dental PPO and HMO

• Delta Dental Enrollment/Cancellation/Change Form for Retirees

Insurance Cancellation Forms

• Retiree Medical Cancellation Form

Savings Plan Forms

• Envoy Services – Instructions for Distributions/Withdrawals/Loans
• Envoy Services – Transaction Request Form

Long-Term Care Insurance Forms

• Class 004 Long-Term Care Enrollment Form
• Class 004 Long-Term Care Checklist
• Long-Term Care Medical Questionnaire