Human Resources Forms

 
Employee Notification of Change Forms:
Change of Address (PDF)
Paycheck Release Authorization (PDF)
2017 Federal Withholding W-4 (PDF)
2017 State DE4 (PDF)
Authorization for Direct Payroll Deposit (PDF)

CALPERS MEDICAL,DENTAL,VISION AND OPTIONAL LIFE INSURANCE RATES
Effective January 1, 2017
Mayor and City Council - (PDF)
($1,594.00 Monthly Allowance w/ Cap)
Full-Time and CPT Employees/City Clerk and City Treasurer - (PDF)
($1,594.00 Monthly Allowance w/ Cap)
Eligible Part-Time and Temporary Employees - (PDF)
($128.00 Monthly Allowance)
Eligible AFSCME Part-Time Employees w/8 years plus - (PDF)
($442.00 Monthly Allowance for Optional Benefits)

CalPERS - More Documents:
Medical Report for the CalPERS Disabled Dependent Benefit (PDF)
Member Questionnaire for the CalPERS Disabled Dependent Benefit (PDF)
The Prescription for Quality Health Care (PDF)
CalPERS 3% @60 GRID PLUS LOCAL MISC BENEFITS (PDF)
PLANNING YOUR SERVICE RETIREMENT (PDF)
CalPERS COBRA Continuation Coverage (PDF)
CalPERS - A Guide to Complete Your Disability Retirement Election Application (PDF)
CalPERS - A Guide to Employment after Retirement
CalPERS - Affidavit of Parent-Child Relationship (PDF)
CalPERS - Declaration of Health Coverage (PDF)
CalPERS - Election of Optional Membership - Elective Officer (PDF)

CalPERS - Health Benefit Summary - 2017 (PDF)

CalPERS - Health Enrollment / Change Form (PDF)
CalPERS - Health Program Guide (PDF)
CalPERS - Justification for Absence of Spouse or Registered Domestic Partner's Signature (PDF)
CalPERS - Pre-Retirement Lump Sum Beneficiary Designation Form (PDF)
CalPERS - Retirement Allowance Estimate Request (PDF)
CalPERS - Service Credit Purchase Options (PDF)
CalPERS - Service Retirement Election Application Booklet (PDF)
CalPERS - Special Power of Attorney (PDF)
Blue Cross Member Claim Form (PDF)
 
Premier Access Dental:
Premier Access - A Welcome Letter (PDF)  
Premier Access - Certificate of Insurance (PDF)  
Premier Access - Claim Form (PDF)
Premier Access - Employee Enrollment/Change Form (PDF)
Premier Access - Employee Enrollment/Change Form (Spanish/Espa�ol) (PDF)
Premier Access - Federal and State COBRA Election Enrollment Form (PDF)
Premier Access - Grievance Form (PDF)
Premier Access - Individual Waiver Statement (PDF)
Premier Access - Los Angeles Directory (949 pages) (PDF)
Premier Access - Orange County Directory (388 pages) (PDF)
Premier Access - Summary of Benefits (PDF)  
 
Cigna:
How to Report a Life ADD Claim (PDF)
How to Report an STD LTD Claim (PDF)
City of Carson EAP Brochure (PDF)
Value Add Descriptions Cigna (Life ADD) (DOC)
Understanding your options to continue life insurance coverage - Portability and Conversion (PDF)
Portability of Voluntary Term Life Insurance (PDF)
Conversion of Group or Employee Life Insurance to an Individual Policy (PDF)
Group/Association - Short Term Disability Benefits (PDF)
Group Long Term Term Disability (PDF)
Group/Association - Proof of Loss Life Insurance Accidental Death Insurance (PDF)
 
Medical Eye Services (MES)
MES - Policy Certificate (PDF)
MES - Vision Gerber Enrollment Form (DOC)
 
VOYA 457 Deferred Compensation:
Acceptance Letter for 457 Plans / Programs (PDF)
Adjustment Form (PDF)
Beneficiary Designation - Non-Erisa (PDF)
VOYA - 401(a) Group Variable Annuity - Retirement Plan Enrollment Form (PDF)
Employee Data Change Request (PDF)
Employee Termination / Retirement Witdrawal Request Education, Healthcare and Governmental Markets (PDF)
Enrollment Packet 457 (PDF)
Installment Loan Application and Promissory Note Government Retirement Plans (PDF)
Leave of Absence Request (PDF)
Miscellaneous Withdrawal Request Education, Healthcare and Governmental Markets (PDF)
Participation Agreement Governmental 457(b) Retirement Plan (PDF)
Top 10 Reasons to Participate (PDF)
Withdrawal and Transfer Request for Purchase of Governmental Defined Benefit Plan Service Credit - Instructions (PDF)
 
PARS (Public Agency Retirement Services):
PARS - General Information (PDF)
PARS - Request for Distribution (Fillable PDF)
PARS - Designation of Beneficiary Form (PDF)
 
Take Care By Wage Works:
Take Care by WageWorks - Dependent Care (Howt o File a Claim for Approval) (PDF)
Take Care by WageWorks - HealthCare Account (Howt o File a Claim for Approval) (PDF)
Eligible Expenses for Your take care by WageWorks (PDF)
 
Others:
Health Care FSA Reimbursement Claim Form (PDF)
EDD EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE (PDF)
IRS Announcement on Pension Plan Limitations for 2010
 
Memos:
FMLA Packet (PDF)
 
New Hire Clearance Packets
1. Adults Aquatics New Hire Clearance Packet (Fillable PDF)
2. Minors Aquatics New Hire Clearance Packet (Fillable PDF)
3. Part-Time Minors New Hire Clearance Packet (Fillable PDF)
4. Part-Time / Temp / Sports Officials (Non-Minors) New Hire Clearance Packet (Fillable PDF)
5. Adults Full-Time / Elected / Appointed New Hire Clearance Packet (Fillable PDF)
6. Full-Time Employee Benefit Orientation Forms Packet (Fillable PDF)
 

City Hall Contact

701 E Carson Street
Carson, CA 90745
(310) 830-7600, 7 AM - 6 PM
Monday - Thursday
24-hour automated: (310) 952-1700

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