Current Employee Forms

• 2024-2025 YCCD Active Employees Medical Benefit Plans and Rates
• Address Change Form (Mailing address/legal residence - documentation may be required)
• SISC III Change Form (Name, marital status, dependent eligibility)
  • Note:  Changes must be submitted with appropriate documentation within 31 days of event (marriage, birth, etc.).
• Kaiser HMO Enrollment Form Click Here
• SISC Blue Shield Enrollment Form
• Payroll Authorization Form (POP form) - (required for 80%-C, 90%-G, or 100%-D plan choices)
• Blue Shield PPO Medical Claim Form (Medical bills reimbursement)
• American Fidlelity Flex Spending Account  To file a claim: https://americanfidelity.com/support/hcfsa/ - Contact Payroll Department at (209) 575-6538 for more information

• Dental/Vision Enrollment

Be sure to check www.DeltaDentalIns.com to see if your dentist accepts the Premier/Incentive plan or the PPO plan.

• Basic Life Insurance Enrollment/Beneficiary Form
• Voluntary Life Enrollment Form
• Voluntary Life Insurance Info & Rates
• Beneficiary Change Form