{"id":11653,"date":"2025-02-03T08:52:43","date_gmt":"2025-02-03T16:52:43","guid":{"rendered":"https:\/\/www.palomar.edu\/hr\/?page_id=11653"},"modified":"2025-11-24T15:28:35","modified_gmt":"2025-11-24T23:28:35","slug":"benefit-forms","status":"publish","type":"page","link":"https:\/\/www.palomar.edu\/hr\/benefit-forms\/","title":{"rendered":"Benefit Forms"},"content":{"rendered":"\n<p><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>403(b) and 457(b) Forms\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2021\/03\/403-200-SF-Salary-Reduction-Agreement.pdf\">403(b) Contribution Change Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/12\/457b-Salary-Reduction-Agreement-SRA.pdf\">457(b) Contribution Change Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/12\/403b-rollover.pdf\">403(b) Distribution Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/12\/457distribution-form.pdf\">457(b) Distribution Form<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Dental Forms\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhBbvoSqIJjTuP8uocFdYsBQnyfIVF2spW2YDuXUgYIIwY3fTugPOn3ptHibSnUgcPY%2A\">Delta Premier PPO Plan Enrollment Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhBNeHPgV1HJ_0NrimwK7dLIwx5HeZyGmJ8q-t3vguzR6rBAZ-pwu2BTB-OFaoF0Dw0%2A\">Delta PPO Plan Enrollment Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhCO5HXX2v1w3mKfHjS-UbkDdReUKEpVLQL2qtAwKsPt0E6Yt5qk1srXWxy0B1PvuJE%2A\">DeltaCare USA DHMO Plan Enrollment Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/Delta-Dental-claim-form.pdf\">Delta PPO claim form<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Life and Long-Term Disability Forms\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/palomar.na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhAIjIkYjerRiHpOVH5kwELrgk82cqNjoe1F1uHk6QNQlmMu71SNsjtzeQrK0mUxsPI*\">VOYA Term Life Beneficiary Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhCxarMalAUdPC4zk0qDfETliumt-xcoj44VMK_qVbfQC3y9Qrl25EVolGitXNVlzSY%2A\">VOYA Voluntary Life and AD&amp;D<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2019\/01\/VOYA-How-to-File-A-Claim.pdf\">Long Term Disability: how to file a claim<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Medical Forms\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/Marriage.Affidavit.pdf\">Marriage Affidavit Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhBgZQNkQMzkFl0hC9obAhCMHHQ9ltrTnif-4bfF1uMA5p9V-LttNqkiVlS3L0yslC0%2A\">Kaiser HMO Enrollment and Change Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhAqvaFRqM__7IpyBJ6mtEhrDjqoVa-F6FSwRGj3amu3TbsYjroP6SLzm7r1XH6rzHQ%2A\">Kaiser HSA Enrollment and Change Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhCHFhEanLG-CyuD_7z9Lh_vm1ofPLmowc0tqcpFvgjUR7--G9w-aTSsKOTHMm_CHTg%2A\">Anthem HMO Enrollment and Change Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhAvTP2htOi4CZvZ5nJURF2Mg7UeHcw-HHWB6up_VqJjbPm7lYbscSRK9gKTirTSFdg%2A\">Anthem PPO 100A Enrollment and Change Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhCwswGRaZrXWWFmGroI5a-9imoZPyDIGz7C_LT2GG1Um79lODsm1N06_JM4je6I8yA%2A\">Anthem PPO 80E Enrollment and Change Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/PPO-CA_member_claim_form_01-13-15.pdf\">Anthem PPO Claim Form<\/a> (fax 866\/444-3816) <\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/TA-form-PW_C130307.pdf\">PPO Transition Care Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/Costco-Mail-Registration-Form.pdf\">Mail Order Rx Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhAuGasPXdrl2f3T03VhDy3IJusbV73C4lNpSTGtTOFgHwS67ToJn4Vc1O8mWzIHzOM%2A\">Health Insurance Opt Out Form<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Vision Forms\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhDtF5qnk3hpAwMmJedpRh8cZElx-qnK3E2Rk-6Kklo_gOn-gmZqBEnDMgtOGYC_g_0%2A\">EyeMed Vision Enrollment Form<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Retirement Plan Forms\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/na2.documents.adobe.com\/public\/esignWidget?wid=CBFCIBAA3AAABLblqZhDy1rF7EAjzJyFSi25Wm_akW8_To9jZssHQjsX8ZKi70J6nwmSKHPJdwjaqVc3zNJE*\">APPLE Beneficiary<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2021\/03\/APPLE_Monthly_RSA_Form_DOE.pdf\" data-type=\"link\" data-id=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2021\/03\/APPLE_Monthly_RSA_Form_DOE.pdf\">APPLE Distribution Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.calpers.ca.gov\/documents\/pre-retirement-lump-sum-beneficiary-designation\/download\">CalPERS Beneficiary Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.calpers.ca.gov\/members\/retirement-benefits\/service-credit\">CalPERS Service Credit Purchase<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.calpers.ca.gov\/members\/retirement-benefits\/service-disability-retirement\">CalPERS Service Retirement Application<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.calpers.ca.gov\/members\/retirement-benefits\/service-disability-retirement\/power-of-attorney\">CalPERS Power of Attorney<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.calstrs.com\/files\/c004d8691\/PreretirementElectionOption.pdf\">CalSTRS Beneficiary Form<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.calstrs.com\/purchasing-service-credit-faq\">CalSTRS Service Credit Purchase<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/forms.calstrs.com\/CalSTRSOnlineFormRequestWebUI\/Root\/Pages\/OpenAttachment.aspx?FormId=eb03c813-824b-4bfb-a9b4-6fc1c9bdaa14\">CalSTRS Service Retirement<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Voluntary Benefit Forms\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2021\/03\/2020-Hyatt-Legal-Plan-METLAW-ENROLL-FORM-10thly.pdf\">Hyatt Enrollment Form<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Workers Compensation Information\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2024\/09\/Workers-Compensation-Claim-Packet-2022.pdf\">Work Injury Claim Information<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/01\/Notice-to-Employees-PIPS-PRIME-Plus.pdf\">Workers Compensation Information<\/a> (<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2024\/09\/2024.New-Hire-Pamphlet-Spanish.pdf\">Spanish<\/a>)<\/li>\n\n\n\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2025\/08\/Palomar-flowchart_CoNurse_poster.pdf\">Company Nurse 24 Hour Injury Assessment Line<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Orientation Information\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2024\/09\/Oct2024.Benefit.Orientation.pdf\">BenNEO<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/CA.EDD_.de2320.pdf\">EDD<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/FT.Faculty.Contract.Salary.pdf\">FacSal<\/a>,&nbsp;<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/NewHire_Schools-04.2014.pdf\">Work Injury<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/Physician.Predesignation.December.2012.pdf\">Pre-Desig<\/a>,<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/Medicare.Part_.D.CREDITABLE.COVERAGE.DISCLOSURE.NOTICE.2009-1.pdf\">Med<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/10\/HOLIDAY-SCHEDULE-2016-2017.pdf\">Hol<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/Fit.Ctr_.1.month_.free_.pdf\">30D<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/CCE.New_.Employe.Union_.Dues_.Memo_.November.2012.pdf\">Cdue<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/FacultyUnionDuesMemoHR.06.13.pdf\">Fdue<\/a>,<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2019\/01\/HIPAA.pdf\">HIPAA<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2018\/11\/Life_Taxable.pdf\">Ltax<\/a>,<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2018\/11\/COB_Rule.pdf\">COB<\/a>,<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/2016.Student.Cert_.Form_.pdf\">Scert<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/CAST.Benefit.Orientation.pdf\">casto<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/EdAA.Benefit.Orientation.pdf\">crtadmo<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/ClsAA.Benefit.Orientation1.pdf\">clsadmo<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/Class.Benefit.Orientation.pdf\">classo<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/Faculty.Benefit.Orientation.pdf\">faco<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2013\/08\/ECE.Benefit.Orientation.pdf\">eceo<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2020\/02\/HShelp.pdf\">HShelp<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2020\/02\/HSlogin.pdf\">HSlogin<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2019\/09\/TBCB-CA-School-Staff-Volunteer-TB-Risk-Assessment-Final.pdf\">rskassess<\/a>,<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2019\/11\/FINAL.Delinquent.Notification.Page2_.pdf\">TBEnc<\/a> , <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/06\/Anthem.How-to-search-provider-directory.pdf\">A prov srch<\/a> (<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/01\/Employment-Verification.pdf\">EV<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/01\/Fingerprinting-Procedure-Live-Scan-6.2013.pdf\">LS<\/a>\/, <a href=\"http:\/\/Marketplace.2022.pdf (palomar.edu)\">Exch<\/a>, <a href=\"http:\/\/SchoolsFirst Letterhead Electronic (palomar.edu)\">UA<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/01\/PT-FAC-Retirement-Options-Entire-Sheet-2019.pdf\">Ret<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/01\/Welcome-to-Palomar-and-Welcome-to-our-PalomarPOWERED-Professional-Development-Program-3PD.pdf\">PD<\/a>, <a href=\"http:\/\/TBCB-CA-School-Staff-Volunteer-TB-Risk-Assessment-Final.pdf (palomar.edu)\">TB<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/06\/I-9.pdf\">I9<\/a>,<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/06\/10.12PAYagreement_23-24.pdf\">10\/12<\/a>,<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/06\/Oct2023.Benefit.Orientation.pdf\">fto<\/a>, <a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/07\/New-Form-ADM.CAST-Request-for-Live-Scan-Form.pdf\">ADMLS<\/a>,<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/07\/New-Form-CLS-Request-for-Live-Scan-Form.pdf\">CLSLS<\/a>,<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/07\/New-Form-FAC.ADJ-Request-for-Live-Scan-Form.pdf\">FACLS<\/a>,<a href=\"https:\/\/www.palomar.edu\/hr\/wp-content\/uploads\/sites\/157\/2023\/07\/New-Form-STM.STU-Request-for-Live-Scan-Form.pdf\">STM\/ULS<\/a>)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":501,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-11653","page","type-page","status-publish","hentry"],"featured_image_src":null,"acf":[],"_links":{"self":[{"href":"https:\/\/www.palomar.edu\/hr\/wp-json\/wp\/v2\/pages\/11653","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.palomar.edu\/hr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.palomar.edu\/hr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.palomar.edu\/hr\/wp-json\/wp\/v2\/users\/501"}],"replies":[{"embeddable":true,"href":"https:\/\/www.palomar.edu\/hr\/wp-json\/wp\/v2\/comments?post=11653"}],"version-history":[{"count":7,"href":"https:\/\/www.palomar.edu\/hr\/wp-json\/wp\/v2\/pages\/11653\/revisions"}],"predecessor-version":[{"id":12168,"href":"https:\/\/www.palomar.edu\/hr\/wp-json\/wp\/v2\/pages\/11653\/revisions\/12168"}],"wp:attachment":[{"href":"https:\/\/www.palomar.edu\/hr\/wp-json\/wp\/v2\/media?parent=11653"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}