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
- Payroll Deduction Form BS-213
- Kaiser Enrollment/Change Form
- Sutter Health Plus Enrollment/Change Form
- Western Health Advantage Enrollment/Change Form
- Delta Dental Enrollment/Change Form
- VSP Enrollment/Change Form BS-160
Adjunct Insurance Forms
- 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
Vision Services Plan (VSP) 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)
- FSA/DCAP Online Enrollment Instructions
- FSA/DCAP Election Change Form
- FSA Claim Form
- DCAP Claim Form
- Orthodontia Claim Form
Legal Insurance Forms
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
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
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
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 Emergency Family and Medical Leave
- Employee Certification of Need for Paid Emergency Sick Leave
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
- FMLA Certification of Physician or Practitioner
- FMLA Certification of Adoption or Foster Care