Benefits

All Employees

• Affidavit of Marriage/Domestic Partnership [pdf]
• Affidavit of Parent-Child Relationship [pdf]
• Authorization to Use and/or Disclose Personal Health Plan Information (requires SJSUOne/CSU login)
• Benefits Accounts/Receivable Agreement [DocuSign]
• COBRA Continuation Requirements [pdf]
• COBRA Continuation Election Form [docx]
• Declaration of Domestic Partnership
• Dependent Re-verification Affidavit [DocuSign] 
• Disclosure of Privacy Information [pdf]
• eBenefits Self-service Electronic Signature Authorization Form [pdf]
• Election to Continue Direct Pay for Employees on Leave of Absence [DocuSign] 
• New Health Insurance Coverage Options and Your Health Coverage [doc]
• Request for Access to Inspect and Copy Personal Health Plan Information [pdf]
• Request for Accounting of Non-Routine Disclosures of Personal Health Plan Information [pdf]
• Request for Confidential Communications of Personal Health Plan Information [pdf]
• Request for Restricted Use of Personal Health Plan Information [pdf]
• Request to Amend Personal Health Plan Information [pdf]
• Revised CSU Privacy Policy [pdf]
• Tax Sheltered Annuity Final Settlement Deductions [pdf]
• VSP Out-of-Network Reimbursement Form [pdf] (requires SJSUOne/CSU login)
• VSP Computer Vision Glasses Confirmation Form [pdf]

Faculty Specific

(includes Librarians, Counselors and some Coaches)

• Faculty Early Retirement Program Request Form [DocuSign]
• Pre-Retirement Time Base Reduction Program Request form [DocuSign]