Breadcrumb
Benefits Forms
- Benefits Enrollment Worksheet
- Out-of-Network Reimbursement Form
- Video Display Terminal (VDT) Claim Form
The VSP Video Display Terminal (VDT) Confirmation Form is only provided to CSU employees who meet the necessary job requirements as determined by the CSU campus benefits office. This form must be completed by the employee and provided to a VSP Select Network doctor to receive the supplemental VDT benefit. - VSP Premier Enrollment Form
This is an Adobe Sign Form. You will need to log in with your Humboldt username account. Follow the instructions in the landing page.
- Savings Plus Benefits Payment Booklet
This booklet contains information and a payment application to help you select the payment method that best meets your needs.
- Catastrophic Leave Donation Form - Family Care
- Catastrophic Leave Donation Form - Self
- SPSL Request Form
Employee will need to initiate the form and send it to supervisor for review/approval. Supervisor will need to send the completed form to mca33@humboldt.edu. Please make sure the time is also claimed in Absence Management or claimed on the employee's timesheet - Leave Without Pay (LWOP) Application (staff/management)
- CAL-ORE Membership Application
A Cal-Ore Life Flight membership ensures the patient will have no out-of-pocket flight expenses if flown by the Comp
- Career Development Plan
Career Development Plans use an online submission process which provides the opportunity to sign, gain signatures and submit electronically. - Fee Waiver Application - Dependent
- Fee Waiver Application - Self
- Career Development Plan
Career Development Plans use an online submission process which provides the opportunity to sign, gain signatures and submit electronically. - Fee Waiver Application - Dependent
- Fee Waiver Application - Self
- Fee Waiver Application Fee Refund Request
- Claim Form DWC1
Employee’s Report of Injury (DWC-1) – Must be given to employee at the time injury is reported to Supervisor, or as soon as possible after medical treatment is received - Supervisor's Report of Injury
Supervisor’s Report of Injury – MUST BE SUBMITTED TO HUMAN RESOURCES WITHIN 24 HOURS OF KNOWLEDGE OF INJURY - Claim Form DWC1
Employee’s Report of Injury (DWC-1) – Must be given to employee at the time injury is reported to Supervisor, or as soon as possible after medical treatment is received - Supervisor's Report of Injury
Supervisor’s Report of Injury – MUST BE SUBMIT - Pre-Designation of Physician Form
Predesignation of a Personal Physician - Work-Related Injury Reporting Procedure
The document includes links to all the necessary forms for the Workers' Compensation process. - Authorization to Transport Form
Request for Non-Emergency Medical Transportation for Work-Related Injuries
- The Standard Beneficiary Form
Employer Paid Life and AD&D Beneficiary Designation and Change Form
- *HCRA/DCRA Claim Form
Attach supporting documentation and submit to ASIFlex