Forms
HEALTH FORMS
- Change of Address
- Death Benefit Designation
- Declaration of Hours Worked
- Evidence of Disability Form
- Unemployed Self-pay Application (Plan A only)
- Extension of Unemployed Self-pay Coverage (Plan A only)
- Disabled Self-pay Application (Plan A only)
- Application for Extension of Unemployment Self Pay
- Disability Form Plan A
- Disability Form Plan B
- Participant Data Form
- Request for National Subsidy Application
- 2014 Claim Form
HEALTH PLAN A CALIFORNIA PLAN A OPTIONS
- Medical Plan Comparison
- Dental Plan Comparison
- DeltaCare – CA Benefits
- DeltaCare-USA-CA-espanol
- Delta Dental PPO Benefits
- Delta Dental PPO Benefits espanol
- Delta Dental PPO Enrollment Form
- Vision Coverage
- Vision Coverage en espanol
- Vision Coverage Safety Eyewear
- Employee Assistance Program
HEALTH PLAN A NEVADA OPTIONS
- Medical Plan Comparison
- Dental Plan Comparison
- DeltaCare – NV Benefits
- DeltaCare – NV Benefits espanol
- Delta Dental Premier Benefits PPO
- Delta Dental Premier Benefits espanol
- Delta Dental Premier PPO Enrollment Form
- Vision Coverage
- Vision Coverage en espanol
- Vision Coverage Eyewear
- Employee Assistance Program
HEALTH PLAN B CALIFORNIA PLAN B OPTIONS
- Medical Plan Comparison
- DeltaCare – CA Benefits
- DeltaCare – CA Benefits espanol
- Vision Coverage
- Vision Coverage espanol
- Vision Coverage Eyewear
- Employee Assistance Program
HEALTH PLAN B NEVADA OPTIONS
NON-PENSIONERS Forms
- Application Form
- Pension Benefit Election
- Pension Benefit Election – Inactive
- Pension Benefit Election Option – Out-of-State
- Pension Benefit Election Option – Out-of-State – Inactive
- Pension Plan Summary Plan Description (SPD)
- Retiree Health Plan Summary Plan Description (SPD)
- Beneficiary Designation Form
- Direct Deposit Form
- Change of Address Form
NON-PENSIONERS Grace Period Application Forms
