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Enrollment Forms

Enrollment Forms are now located under the Frequently Used Forms page. 

Add dependents outside of Open Enrollment

Dependents must be added within 30 days of a qualifying event, such as marriage, birth, registered domestic partner or loss of coverage. Employee must complete a new enrollment along with required documentation.

2024 Rate Sheets

Effective January 1, 2024 – December 31, 2024

2024 SEIU/Teamsters Early Retiree Rates

2024 SEIU/Teamsters Early 50% Rates

Enrollment Forms

Classified Benefits Enrollment Form

2024 Rate Sheet

Effective January 1, 2024 – December 31, 2024

2024 SEIU/Teamsters Active Rate Sheet

2025 Rate Sheet

Effective January 1, 2025 â€“ December 31, 2025

2025 SEIU/Teamsters Active Rate Sheet

Summary of Benefits and Coverage

2025 Summary of Benefits and Coverage - Kaiser HMO

2025 Summary of Benefits and Coverage - Kaiser HSA SBC

2025 Summary of Benefits and Coverage - Western Health Employee Only

2025 Summary of Benefits and Coverage - Western Health Family

Classified Long-Term Disability Insurance

Classified Disability Insurance Booklet

Classified Disability Insurance Contract

Dental Plan

Delta Dental Information

Enrollment Forms

Enrollment Forms are now located under the Frequently Used Forms page. 

2024 Rate Sheets

Effective January 1, 2024 – December 31, 2024

2024 UnRep Management/Supervisor/Confidential/UPE/TCS Early Retiree Rate Sheet

2024 UnRep Management/Supervisor/Confidential/UPE/TCS Over 65 Retiree Rate Sheet

2024 SEIU/Teamsters Early Retiree Rate Sheet

2024 SEIU/Teamsters Early 50% Retiree Rate Sheet

2024 SEIU/Teamsters Over 65 Retiree Rate Sheet

2024 SEIU/Teamsters Over 65 Retiree 50% Rate Sheet

2025 Rate Sheet

Effective January 1, 2025 â€“ December 31, 2025

2025 UnRep Management/Supervisor/Confidential/UPE/TCS Early Retiree Rate Sheet

2025 UnRep Management/Supervisor/Confidential/UPE/TCS Over 65 Retiree Rate Sheet

2025 SEIU/Teamsters Early Retiree Rate Sheet

2025 SEIU/Teamsters Early 50% Retiree Rate Sheet

Enrollment Forms

Enrollment Forms are now located under the Frequently Used Forms page. 

2024 Rate Sheets 

Effective January 1, 2024 – December 31, 2024

2024 SCTA Early Retiree Rate Sheet

2024 SCTA Over 65 Rate Sheet

2025 Rate Sheet

Effective January 1, 2025 â€“ December 31, 2025

2025 SCTA Early Retiree Rate Sheet

2025 SCTA Over 65 Rate Sheet

Summary of Benefits and Coverages

2025 Summary of Benefits and Coverage - Health Net Seniority Plus

2025 Summary of Benefits and Coverage - Health Net HMO

2025 Summary of Benefits and Coverage - Health Net PPO