Enrollment Forms

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Contact

Phone: 831-454-2241
Email: benefits.questions@santacruzcountyca.gov

** These are NOT the 2026 Open Enrollment forms.

To ensure your 2026 Open Enrollment transaction is processed, please visit the official 2026 Open Enrollment website and use the appropriate forms. **

The County of Santa Cruz has elected to not participate in the Online Health Enrollment Self-Service functionality via myCalPERS so that we may assist employees directly. Be sure to submit all paperwork directly to the Benefits Team for processing.

Dependent Required Documentation (Please Read)

2025 Benefit Plans Provider Contact Numbers and Websites

DocuSign Forms

CalPERS HBD-12

Dental/Vision Enrollment Form

Beneficiary Designation Form

Health Insurance Waiver & Annual Certification

Supplemental Enrollment and Beneficiary Form

2025 H-Care Enrollment Form

2025 D-Care Enrollment Form

2025 FSA Enrollment Form

Affidavit of Domestic Partnership

Statement of Termination of Domestic Partnership

Direct Pay Reimbursement Form

Downloadable Forms

CalPERS HBD-12

HBD-12 Completion Instructions

Dental/Vision Enrollment Form

Beneficiary Designation Form

Health Insurance Waiver & Annual Certification

Supplemental Enrollment and Beneficiary Form

2025 H-Care Enrollment Form

2025 FSA Enrollment Form

Inspira FSA Claim Form

2025 D-Care Enrollment Form

D-Care Account Reimbursement Form

Affidavit of Domestic Partnership

Statement of Termination of Domestic Partnership

Affidavit Parent-Child Relationship

457 Deferred Compensation Enrollment Packet

Direct Pay Reimbursement Form

New Hire Forms

New Hire Benefits Enrollment Instructions

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