Benefits

Current Employee Forms

Most forms are in the interactive PDF format. If further assistance is required, please contact the Benefits Office at (209) 575-6547.

Benefits Forms

For more information on District Benefits, access the applicable link on the left side navigation bar.

Health

2023-2024 YCCD Active Employees Medical Benefit Plans and Rates

Address Change Form (Mailing address/legal residence - documentation may be required)

SISC III Change Form (Name, marital status, dependent eligibility)

Note:  Changes must be submitted with appropriate documentation within 31 days of event (marriage, birth, etc.).

Kaiser HMO Enrollment Form

SISC Blue Shield Enrollment Form

Payroll Authorization Form (POP form) - (required for 80%-C, 90%-G, or 100%-D plan choices)

Blue Shield PPO Medical Claim Form (Medical bills reimbursement)

American Fidlelity Flex Spending Account  To file a claim: https://americanfidelity.com/support/hcfsa/ - Contact Payroll Department at (209) 575-6538 for more information.

Dental/Vision

Dental/Vision Enrollment

Be sure to check www.DeltaDentalIns.com to see if your dentist accepts the Premier/Incentive plan or the PPO plan.

Life Insurance

Basic Life Insurance Enrollment/Beneficiary Form

Voluntary Life Enrollment Form

Voluntary Life Insurance Info & Rates

Beneficiary Change Form