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.
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

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 Company or another AirMedCare Network participating provider

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

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 SUBMITTED TO HUMAN RESOURCES WITHIN 24 HOURS OF KNOWLEDGE OF INJURY

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

Form 310 - Difference in Pay (DIP) Leave Application

Available to eligible faculty unit employees only.
Form 320 - Sabbatical Leave Application

Available to eligible faculty unit employees only.
Sabbatical/DIP Notary Pages

Notary Pages for Approved Sabbatical and DIP Leaves

Form 900 - Request for Participation in Faculty Early Retirement Program (FERP)

Tenured Faculty Unit employees who are of normal retirement age (consistent with CalPERS rules and pursuant to the California Code of Regulations (CCR) §586.1) are eligible to participate in the program.

The Standard Beneficiary Form

Employer Paid Life and AD&D Beneficiary Designation and Change Form

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