Southern California Conference

DEADLINE: December 13, 2018

Read-this-memo-FIRST

Open Enrollment Forms

1. ALL ELIGIBLE EMPLOYEES MUST COMPLETE THIS OPEN ENROLLMENT SELECTION FORM, even if you are opting out or have other coverage!
2. Breakdown of costs: 2019 Deductibles and Copays
3. MARRIED EMPLOYEES ONLY: Spouse Application Form
4. EMPLOYEES WITH DEPENDENT CHILDREN ONLY: Dependent Election Form
5. Complete the appropriate Savings or Spending Account form:
   1. If you have PPO: Health Savings Account (HSA)
   2. If you have HMO: Flexible Spending Account (FSA)
6. If you wish to DECLINE health care: HCAP Declination Form
7. If you wish to DECLINE health care but buy into DENTAL and VISION
8. If you want to CHANGE plans, contact Human Resources (hr@sccsda.org) for the appropriate forms
9. If you had declined Health Care in the PAST but now wish to enroll, contact HR (hr@sccsda.org) for the appropriate forms
10. SUPPLEMENTAL INSURANCE PLANS:
    1. Supplemental Life (SL) and Accidental Death & Dismemberment (AD&D) insurance Info Sheet
    2. SL insurance rates
    3. AD&D insurance rate
    4. SL and AD&D insurance application form

Other Health Care Forms

1. Contact Change Notification Form
2. Physical Exam Incentive Form

FAQ