Human Relations

Forms and Documents

Here are all the Employee Benefits online forms and documents in one location.

Important Health Coverage Tax Documents Available

• Notice Regarding IRS Form 1095-C for the 2025 Tax Year

Health Insurance Forms and Documents

• Stanislaus Benefits eGuide
• Employee Benefit Enrollment Form (Download and Open File in Adobe Reader to Sign and Return)
• Benefit Summaries
• 2025 Rate Sheet
• 2026 Rate Sheet
• Adobe Reader Download

Medical Plan Information - HPNC and UHC

• Local Service Area Zip Code List
• HPNC HDHP Summary of Benefits and Coverage Notice (SBC)
• HPNC EPO Summary of Benefits and Coverage Notice (SBC)
• UHC HDHP Summary of Benefits and Coverage Notice (SBC)
• UHC EPO Summary of Benefits and Coverage Notice (SBC)
• Summary Plan Description (SPD) for Stanislaus County Health Plan

Prescription Pharmacy Network

• CVS Caremark Pharmacy Mail Order Form
• CVS Caremark Prescription Reimbursement Claim Form

Dental Plan Information - Delta Dental

• Delta Dental Core Plan Information
• Delta Dental Buy Up Plan Information
• Delta Dental Core Evidence of Coverage
• Delta Dental Buy Up Evidence of Coverage

Vision Plan Information- VSP

• Vision Service Plan Description

Life Insurance and Long Term Disability- Voya/ReliaStar

• Voya/ReliaStar Group Term Life Insurance at a Glance
• Voya/ReliaStar Life Insurance Evidence of Insurability (EOI)
• Voya/ReliaStar EOI Instructions
• Voya/ReliaStar Life Insurance Policy
• ReliaStar Management Long Term Disability Policy
• ReliaStar Management Long Term Disability Summary

Accident Insurance

• Compass Accident Insurance Brochure
• Compass Wellness Benefit Test Requirement
• How to File a Wellness Claim
• Compass Accident Wellness Benefit Claim Form
• Compass Accident Insurance Claim Form

Critical Illness Insurance

• Compass Critical Illness Insurance Brochure
• Compass Wellness Benefit Test Requirement
• How to File a Wellness Claim
• Compass Critical Illness Wellness Benefit Claim Form
• Compass Critical Illness Insurance Claim Form
• Compass Critical Illness Insurance Physician Statement

Health Savings Account - OPTUM Bank

• 2026 HSA Payroll Contribution Form

Flexible Spending Accounts - P & A Group

• Health Flexible Spending Account
• Dependent Care Assistance Flexible Spending Account
• FSA Qualified Expenses
• FSA Direct Deposit Authorization Form
• FSA Claim Form

457 Deferred Compensation - Nationwide

• Deferred Compensation Virtual Enrollment Kit
• Deferred Compensation Enrollment Link
• Beneficiary Form
• Tax Planning Quick Reference Guide

401a Plan - Nationwide

• 401a SSA-1945 Cover Letter
• 401a SSA-1945 Notification
• Government Pension Offset Info
• Windfall Elimination Provision Info

eBenefits

• PeopleSoft Self Service Information

Manhattan Life (formerly Humana)

• Policy Cancellation Form
• Health Screening Benefit Form
• Critical Illness Claim Form

Health Insurance Information after Termination or Retirement

• Health Insurance Continuation - For participants leaving employment and currently enrolled in Stanislaus County health insurance.
• Retiree Medical Insurance - For StanCERA members not currently enrolled in Stanislaus County health insurance