Benefits Forms & Resources | County of Riverside Human Resources

Benefits Forms & Resources

Employee Health Benefits

2025 Benefit Election Form

2025 Decline Coverage Acknowledgment Form

2025 Active Employee Benefit Guide

2025 CalPERS Health Benefit Summary

2025 CalPERS Health Program Guide

My|CalPERS Login

CalPERS Medical Plan Enrollment Form (HBD12)

Instructions for CalPERS Medical Plan Enrollment Form (HBD12)

Affidavit of Parent-Child Relationship HBD-40

Medical Report for the CalPERS Disabled Dependent Benefit (HBD-34)

Other CalPERS Forms and Publications

TAP & Per Diem Employee Health Benefits

2025 TAP & Per Diem Flyer

Affidavits / Declarations

Declaration of Tax Dependent Status
Cafeteria Plan Document

Consolidated Omnibus Budget Reconciliation Act (COBRA)+

2025 COBRA Election Form

2025 COBRA Rate Sheet

Notice of Rights and Obligations

Life Insurance

Certificate of Coverage 641685-E (All other)

Certificate of Coverage 641685-F (SEIU/LIUNA)

The Standard Life Coverage Conversion Package

The Standard Life – Portability Application

Flexible Spending Accounts

Dependent Care FSA Plan Document

Health FSA Plan Document

ASI Direct Deposit Application

ASI Flex Card Order Form

Letter of Medical Necessity

Automatic Claim Request Form for DC FSA

Retiree Health Benefits

2025 Retiree Benefits Guide

2025 Retiree Benefit Election Form

Retiree Change Form

Retiree Cancellation Form

Health Benefits Plan Enrollment for Retirees and Survivors (HBD-30)

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Employee Benefits
Employee Health Benefits
Disability Insurance
Life Insurance
Retirement Plans
Retiree Health Benefits
Other Benefits
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