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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
2024-2025 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 Click Here
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
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