Enrollment Forms

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Phone: 831-454-2241
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Online Health Enrollment Self-Service for Active Employees is available in myCalPERS. However, use of this functionality is at the discretion of your employer. At this time, Benefit Enrollment Forms, must be submitted directly to the Benefits Team for processing.

Dependent Elgibility Requirements (Please Read)

DocuSign Forms

CalPERS HBD-12

Health Insurance Waiver & Annual Certification

Dental/Vision Enrollment Form

Beneficiary Designation Form

Supplemental Enrollment and Beneficiary Form

2023 D-Care Enrollment Form

2023 H-Care Enrollment Form

2023 FSA Enrollment Form

Affidavit of Domestic Partnership

Statement of Termination of Domestic Partnership

Direct Pay Reimbursement Form

457 Deferred Compensation Deduction Form

Downloadable Forms

457 Deferred Compensation Deduction Form

CalPERS HBD-12

HBD-12 Completion Instructions

Health Insurance Waiver & Annual Certification

Dental/Vision Enrollment Form

2023 H-Care Enrollment Form

2023 D-Care Enrollment Form

D-Care Reimbursement Account Claim Form

2023 FSA Enrollment Form

PayFlex Claim (FSA) Reimbursement Form

Affidavit Parent-Child Relationship

Affidavit of Domestic Partnership

Statement of Termination of Domestic Partnership

Direct Pay Reimbursement Form

Supplemental Enrollment and Beneficiary Form

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