Forms & Notices
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General Use (All Plans)
Health & Welfare
Blue Shield of CA HMO Plan Summary of Benefits & Coverage – July 1, 2021
Blue Shield of CA PPO Plan Summary of Benefit & Coverage – July 1, 2021
Kaiser Active HDHP Plan Summary of Benefits & Coverage – July 1, 2021
Kaiser Retiree HDHP Plan Summary of Benefits & Coverage – July 1, 2021
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
Notice of Creditable Coverage – October 2018
Points Account – Premium Payment Reimbursement Request
Retiree Self-Pay Rates – July 2021
Pension - Defined Benefit
Change of Beneficiary Designation
Direct Deposit Electronic Funds Transfer Request
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