my eligibility to enroll in health and dental benefits

							                        State of California • Arnold Schw arzenegger, Governor
                        State and Consumer Services Agency
                        DEPARTMENT OF GENERAL SERVICES
                        Office of H uman Resources
                        707 Third Street  West Sacramento, CA 95605  (916) 376-5000  Fax (916) 376-5018 • w w w . d g s . c a . g o v




                              INITIAL NOTIFICATION OF BENEFITS

 Employee Name:                                      ABMS #:                                   Date of Hire:




 Attendance Clerk:




The attendance clerk named above has notified me of my eligibility to enroll in
health and dental benefits. I understand that I have 60 days from the date of
my hire to sign up for these benefits by submitting the appropriate enrollment
forms to my attendance clerk or directly to the Personnel Transaction Unit
located at 707 3rd St., Suite 7-130, West Sacramento, CA 95691.

I understand that if I elect to take up to 60 days to submit the completed
enrollment documents for benefits that this will delay the effective date of my
benefits and may also cause multiple deductions to be taken from one pay
warrant or an account’s receivable to be established by State Controller’s Office
for collection of my portion of the deduction.

If I fail to meet the 60-day deadline, I must wait for an open enrollment period in
order to apply for these benefits or sign up under HIPAA provisions which allow
for an enrollment effective date of the 1st of the month following a 90-day
waiting period from the date the form is signed.

I have also been notified of the additional costs associated with dependent
vesting for new hire employees.


EMPLOYEE: Please sign and date this form and return it with your
completed enrollment forms.


 Employee Signature                                                        Date




                                 http://www.ohr.dgs.ca.gov/Toolkits/actoolkit.htm




                      BUILDING GREEN          •    BUYING GREEN           •    WORKING GREEN
                          INITIAL NOTIFICATION OF BENEFITS
                                 INFORMATION SHEET


I can obtain more information regarding health benefits at:
CalPERS Website                     http://www.calpers.ca.gov/index.jsp?bc=/member/health/home.xml
  Health Plan Info
  Rates
  Health Plan Chooser
Department of Personnel             http://www.dpa.ca.gov/benefits/employer-contribution/2008.htm
Administration Website
  State Contribution
  Dependent vesting
CalPERS Phone #                     1-800-225-7377
  Health Plan Info
  Rates
  Dependent Vesting



I can obtain more information regarding dental benefits at:
Dept. of Personnel Admin Website    http://www.dpa.ca.gov/benefits/dental.htm
  Dental Plans
  Enrollment information
  Enrollment form (STD692)
  Cost Comparison Chart
Dept. of Personnel Admin Website    http://www.dpa.ca.gov/textdocs/freepmls/PML2007023_C.PDF
  Rates
  State Share
Dental Plans
  Delta Dental                     1-800-225-3368
  DeltaCare USA                    1-800-422-4234
  Safeguard                        1-800-880-1800



I can obtain more information regarding vision benefits at:
Dept. of Personnel Admin Website    http://www.dpa.ca.gov/benefits/vision.htm
  Vision Plan Information
  Enrollment information
  Enrollment form (STD700)
  Premiums and deductibles
Dept. of Personnel Admin Website    http://www.dpa.ca.gov/textdocs/freepmls/PML2007023_C.PDF
  Rates
  State Share
Vision Services Plan                1-800-877-7195