Forms & Notices
All PDF files on this website require the most current version of Adobe Reader to view. If you do not have the most current version of Adobe Reader, you can get it by clicking the icon below.
General Use (All Plans)
Health & Welfare
Blue Shield of CA HMO Plan Summary of Benefits & Coverage – July 1, 2022
Blue Shield of CA PPO Plan Summary of Benefit & Coverage – July 1, 2022
Kaiser Active HDHP Plan Summary of Benefits & Coverage – July 1, 2022
Kaiser Retiree HDHP Plan Summary of Benefits & Coverage – July 1, 2022
Authorization for Automatic Deduction of Health & Welfare Payment
Authorization for Release of Protected Health Information (PHI)
Change of Beneficiary – Life Insurance Only
COBRA Continuation of Coverage Election
Incapacitated Child – Request for Continued Coverage
Life Insurance – Group Policy 000010051405
Life Insurance – Lincoln Financial Employee Contact Guide
Notice of Creditable Coverage – October 2023
Notice of Creditable Coverage – October 2022
Notice of Creditable Coverage – October 2018
Points Account – Premium Payment Reimbursement Request
Retiree Self-Pay Rates – July 2021
Pension - Defined Benefit
State of California Form DE-4P
Change of Beneficiary Designation
Change of Beneficiary Affidavit
Eligible Rollover Distribution
Eligible Rollover Distribution for Non-Spouse Beneficiaries
Federal & State Tax Withholding
Notice of Endangered Status 2019
Notice of Endangered Status & Funding Improvement Plan – April 2018
Sep 2021 – RMD Beginning Date for 5% Owners
Pension - Defined Contribution
SAR – Fiscal Year Ended 12/2021
Policy for Partial Holdback of Distributions
Sep 2021 – RMD Beginning Date for 5% Owners
SAR – Fiscal Year Ended 12/2020
Application for Hardship Withdrawal
Eligible Rollover Distribution
Eligible Rollover Distribution for Non-Spouse Beneficiaries
Application for Distribution with Rollover Tax Forms
Participants Whose Homes Were Damaged by California Wildfires – May 2018
Right to Defer Your Defined Contribution Plan Distribution