Forms
This section provides County of Alameda (County) employees with benefit-related forms. You will find electronic copies of the forms (noted as “pdf), or you may be directed to a site outside of the Employee Benefits Center (EBC) Online to access the appropriate form (noted as “html”). If you are directed to another Web site, a new browser window will open. To return to the EBC Online site, simply close the new browser window.
Commuter Benefit Enrollment/Change Form
Commuter Benefit Enrollment/Change Form
Use this form to enroll in the Commuter Benefit Plan, or to change or stop your current payroll deductions.
Document Certification Forms
New Hire Document Certification Form
New Hires complete this form when adding new dependents and/or enrolling or continuing Share the Savings. You are required to submit supporting documentation along with a Document Certification form.
Domestic Partnership
Domestic Partnership Information Packet
Read this packet and return the Domestic Partner Affidavit (pages 4-5) to the EBC if you wish to enroll your domestic partner and/or domestic partner’s eligible dependents for benefits coverage. You also use this form to indicate the dissolution of a domestic partner relationship, if necessary.
Health & Insurance Benefits
Kaiser HMO Transition of Care Form
This document explains the process for transitioning of care for someone who is enrolling in Kaiser HMO for the first time.
UHC HMO Transition of Care Form
Use this form during annual Open Enrollment if you are enrolling in a UHC plan for the first time.
UHC Mail Order Rx Form
Use this form to order your prescriptions through mail order and save money on your copay for an increased supply. Please refer to the schedule of benefits for details.
Life & Disability
Spousal Consent Form
This form should be completed by your spouse if you are designating more than 50% of your Life Insurance to someone other than your spouse.
Disability Insurance Termination Form
Complete this form for termination of Short and/or Long-term Disability coverage. The completed original form should be sent to the Employee Benefits Center at 1405 Lakeside Drive, Oakland, CA 94612, or via QIC to 25701. Do not fax this form to the Employee Benefits Center; an original signature must be on file.
Beneficiary Designation Change Form
Return this form to the EBC to designate your beneficiaries for employee Basic Life Insurance and Supplemental Life Insurance (if eligible). If you wish to change your beneficiaries, you may resubmit this form to the EBC at any time.
Reimbursement Claim Forms
Vision Reimbursement Plan Claim Form for Represented Employees
If eligible for the vision reimbursement program, return this form along with receipts for eligible expenses, to the Office of the Auditor-Controller for reimbursement.