Appointment Paperwork – New-To-State Employee
Complete all applicable documents.
Questions will be addressed during On-Boarding with a Personnel Staff Member.
Benefit Forms
- Dental Plans for Active Employees Directory of State-Sponsored Dental Plans
- 2021 Consolidated Benefits Handbook
- 2021 Summary of Benefits and Coverage Notice
- Affidavit of Parent-Child Relationship (CalHR 025)
- Affidavit of Parent-Child Relationship (HBD-40)
- Affordable Care Act Notification
- Basic Group Term Life Insurance for Excluded Employees
- California State Employee Benefits Quick Reference Guide
- CalPERS 2021 State Health Premiums Rates (Actives and Annuitants)
- CalPERS Beneficiary Designation (PERS-BSD-241)
- Cash Option Enrollment Authorization (STD. 701C)
- CCPOA Benefit Trust Fund Primary Dental Plan (Bargaining Unit 6 employees only)
- Consolidated Benefits (COBEN) (Information)
- Consolidated Benefits (COBEN) Cash Enrollment Election (STD. 702) (Bargaining Units 2, 7, 8, 16, 17, 18, or 19 and Excluded)
- Dental Benefits Handbook
- Dental Plan Enrollment Authorization (STD. 692)
- Dental Program (Information)
- Dependent Eligibility Verification Checklist (CalHR 781)
- FlexElect Handbook – CalHR
- FlexElect Reimbursement Claim Form (CalHR 351)
- Group Legal Services Insurance Plan Enrollment Form – Access Code 10202soc
- Health Benefit Plan Enrollment Form (PERS-HBD-12)
- Health Program Guide
- Lactation Accommodation Employee Acknowledgement (CDCR 1135)
- Life Insurance Enrollment Form (STD. 698)
- Physician Designation (Page 7)
- Premier Vision Plan Enrollment Authorization (CalHR 774)
- Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
- Reimbursement Account Enrollment Authorization (STD. 701R)
Benefits forms for Managers, Supervisors, and Exempt
- CalHR State of California Supervisor Handbook (Managers and Supervisors)
- Compensation Plus Handbook (Managers, Supervisors, Confidential, and Excluded)
- Employee Assistance Program Supervisor Handbook (Managers and Supervisors)
- Group Long Term Disability (LTD) – Excluded State Employees Only (Information) To enroll visit The Standard Insurance Company website and select Enroll Now.
Personnel Forms
- A Guide to the CalPERS Special Power of Attorney (PUB 30)
- Annual Leave-Sick Leave/Vacation Election Form (CalHR 875)
- CalPERS Beneficiary Designation (PERS-BSD-241 form)
- CalPERS Beneficiary Designation webpage
- CalPERS Justification for Absence of Spouse or Registered Domestic Partner’s Signature
- CalPERS Member Reciprocal Self-Certification Form
- Catastrophic Time Bank (CTB) Request (CDC 868)
- Catastrophic Time Bank Donation Authorization (CDC 869)
- Designation of Person(s) Authorized to Receive Warrants (STD. 243)
- Direct Deposit Enrollment Authorization (STD. 699)
- Election Of Optional Membership – State Appointee – CalPERS 0842 – CalPERS optional membership form (if applicable)
- Military Service Declaration (STD. 912)
- New California State Employee’s Guide to Workers’ Compensation 13546.pdf (statefundca.com)
- Verification of State Service outside the Executive Branch (CalHR-039)
- Wounded Warriors Transitional Leave Act Acknowledgement HR (2000)
Forms provided by Personnel Liaison
- 2020 Annual TB Detailed Instructions (Intranet)
- 2020 Tuberculosis Testing / Evaluation Page (Intranet)
- Employee Action Request (STD. 686)
- California Department of Corrections and Rehabilitation Secretary’s Welcome Letter (2019)
- Computing Technology Use Agreement (CDC 1857)
- Emergency Notification Information (CDCR 894)
- Employee Tuberculin Skin Test and Evaluation (CDCR 7336)
- Employment Eligibility Verification (Form I-9)
- Live Scan Fingerprint Intake Form
- Oath of Allegiance and Declaration of Permission to Work for State of California employees (STD. 689)
- Personnel Identification Card Information (Intranet) CDCR 894-A
- Pre-Tax Parking Payroll Authorization (CDCR 1164) HQ Only
- Request for Live Scan Service (Intranet) CDCR 3056
- State Employee Race/Ethnicity Questionnaire (CalHR 1070)
- TB Infectious Free Staff Certification CDCR 7354
- Zero Tolerance Regarding the “Code of Silence” Memorandum
Revision 09/2021