Employee benefits forms for active Los Rios employees.
Health Insurance Forms
Insurance Enrollment and Change Forms
- Payroll Deduction Form BS-213 (PDF)
- Kaiser Enrollment/Change Form (PDF)
- Sutter Health Plus Enrollment/Change Form (PDF)
- Western Health Advantage Enrollment/Change Form (PDF)
- Delta Dental Enrollment/Change Form (PDF)
- VSP Enrollment/Change Form BS-160 (PDF)
Adjunct Insurance Forms
- Health Insurance Certification Form BS-114 (PDF)
- Request for Inclusion of Sierra College FTE Form BS-51 (PDF)
- Adjunct Medical Insurance Cancellation Form BS-211 (PDF)
- Adjunct Medical Plan Waiver Form BS-216 (PDF)
Vision Services Plan (VSP) Forms
Domestic Partner Forms
- Domestic Partner Affidavit of Domestic Partnership Form BS-209 (PDF)
- Termination of Domestic Partnership (PDF)
Insurance Waiver Forms
Insurance Cancellation Request
For regular permanent employees:
Legal Insurance Forms
HSA/FSA Forms
Health Savings Accounts (HSA)
Flexible Spending Accounts (FSA)
- FSA/DCAP Online Enrollment Instructions (PDF)
- FSA Claim Form (PDF)
- DCAP Claim Form (PDF)
- Orthodontia Claim Form (PDF)
Long-Term Care Insurance Forms
Class 001 – Classified Staff Working at Least 20 Hours Per Week
- Class 001 Long-Term Care Enrollment Form (PDF)
- UNUM Checklist of Delivered Forms (PDF)
- Long-Term Care Medical Questionnaire (PDF)
Class 002 – Certificated Staff Working at Least 50%
- Class 002 Long-Term Care Enrollment Form (PDF)
- UNUM Checklist of Delivered Forms (PDF)
- Long-Term Care Medical Questionnaire (PDF)
Class 003 – Adjunct/Permanent Part-Time Staff (Not Qualified for Class 001 or 002)
- Class 003 Long-Term Care Enrollment Form (PDF)
- UNUM Checklist of Delivered Forms (PDF)
- Long-Term Care Medical Questionnaire (PDF)
Life Insurance Forms
- UNUM Beneficiary Form (PDF)
- UNUM Voluntary Life & ADD Enrollment Form for Monthly Employees (PDF)
- UNUM Voluntary Life & ADD Enrollment Form for Tenthly Employees (PDF)
Retirement Savings Plan Forms
403B Savings Plan
457 Savings Plans
Retirement Savings Distributions
- Envoy Services – Instructions for Distributions/Withdrawals/Loans (PDF)
- Envoy Services – Transaction Request Form (PDF)
Leave Forms
Five Month Law
- Five Month Law Physician's Verification Form (PDF)
- Verification of Illness Form (PDF) – Not for use for 5 Month Law or Catastrophic Leave
Catastrophic Leave
Classified Staff
- Application for Catastrophic Leave for Classified and Management Employees BS-185 (PDF)
- Catastrophic Leave Medical Certification Form BS-184 (PDF)
Certificated Staff
- Extended Catastrophic Leave Application for Faculty Form BS-200 (PDF)
- Authorization for Release of Faculty Medical Information Form (PDF)
- Extended Catastrophic Leave Medical Certification for Faculty Form BS-201 (PDF)
Family Medical Leave Act (FMLA)
- FMLA Request Form BS-186 (PDF)
- FMLA Certification of Physician or Practitioner (PDF)
- FMLA Certification of Adoption or Foster Care (PDF)