New! Updated COVID Leave Form
The COVID leave form has been updated in May 2022.
Employee benefits forms for active Los Rios employees.
Absence Reports/Timesheets
- Absence Report for Classified Employees Form BS-59
- Absence Report for Certificated Employees Form BS-137
- Classified Employees Differential and Overtime Timesheet BS-139
- Student Help Timesheet Form BS-91
- Temporary Classified Timesheet Form BS-68
Health Insurance Forms
Insurance Enrollment and Change Forms
Adjunct Insurance Forms
- Kaiser Enrollment/Change Form
- Sutter Health Plus Enrollment/Change Form
- Western Health Advantage Enrollment/Change Form
- Delta Dental Enrollment/Change Form
- Health Insurance Certification Form BS-114
- Request for Inclusion of Sierra College FTE Form BS-51
- Adjunct Medical Insurance Cancellation Form BS-211
- Adjunct Medical Plan Waiver Form BS-216
- Adjunct Request to Continue Medical Coverage (LRCFT MOU)
Long-Term Temporary (LTT) Insurance Forms
Domestic Partner Forms
Insurance Waiver Forms
Insurance Cancellation Request
For regular permanent employees:
HSA/FSA Forms
Health Savings Accounts (HSA)
Flexible Spending Accounts (FSA)
- Basic CDA – Dependent Care Eligible Expenses
- Basic CDA – Dependent Care Contract
- Basic CDA – MyCash Account
- Basic CDA – FSA Participant Enrollment Guide
- Basic CDA – Direct Deposit Request Form
- Basic CDA – Reimbursement Request
- Basic CDA – Participant Reference Guide
- Basic CDA – Participant Experience Flyer
- Basic CDA – Medical FSA Election Worksheet
- Basic CDA – Orthodontia Contract
Life Insurance Forms
- UNUM Beneficiary Form
- UNUM Voluntary Life & ADD Enrollment Form for Monthly Employees
- UNUM Voluntary Life & ADD Enrollment Form for Tenthly Employees
Long-Term Care Insurance Forms
Class 001 – Classified Staff Working at Least 20 Hours Per Week
- Class 001 Long-Term Care Enrollment Form
- UNUM Checklist of Delivered Forms
- Long-Term Care Medical Questionnaire
- Request to Change Long-Term Care Coverage
Class 002 – Certificated Staff Working at Least 50%
- Class 002 Long-Term Care Enrollment Form
- UNUM Checklist of Delivered Forms
- Long-Term Care Medical Questionnaire
- Request to Change Long-Term Care Coverage
Class 003 – Adjunct/Permanent Part-Time Staff (Not Qualified for Class 001 or 002)
- Class 003 Long-Term Care Enrollment Form
- UNUM Checklist of Delivered Forms
- Long-Term Care Medical Questionnaire
- Request to Change Long-Term Care Coverage
Leave Forms
Catastrophic Leave
Classified Staff
- Application for Catastrophic Leave for Classified and Management Employees BS-185
- Catastrophic Leave Medical Certification Form BS-184
Certificated Staff
- Extended Catastrophic Leave Application for Faculty Form BS-200
- Authorization for Release of Faculty Medical Information Form
- Extended Catastrophic Leave Medical Certification for Faculty Form BS-201
COVID-19 Leave Certification
- Employee Certification of Need for Supplemental Paid Sick Leave – Updated May 2022
Five Month Law
- Five Month Law Physician's Verification Form
- Verification of Illness Form – Not for use for 5 Month Law or Catastrophic Leave
Family Medical Leave Act (FMLA)
- FMLA Request Form BS-186
- Certification of Health Care Provider for Employee’s Serious Health Condition
- Certification of Health Care Provider for Family Member’s Serious Health Condition
Sick Leave and Vacation Forms
New Hire Forms
Retirement Savings Plan Forms
403B Savings Plan
457 Savings Plans
Retirement Savings Distributions
Questions?
Contact Employee Benefits for more information.