2018 Sunnyvale Benefit Summary

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Enrollment Forms & Links
BENEFITS CALCULATION SHEETS
Use these worksheets to estimate your bi-weekly paycheck costs for benefits.
Calculation Sheet Weblink
2018 COA
1) Click on link above
2) Choose worksheet
3) Click download
2018 Council
2018 Management
2018 PSOA
2018 SEA & Confidential
2018 SEIU Standard
2018 SEIU Grandfathered
ENROLLMENT FORMS
All forms needed to make changes for open enrollment are available below.
Forms Weblink
Health Enrollment & Change Form
Use this form for changes to medical, dental and/or vision.
1) Click on link above
2) Choose desired form(s)
3) Click download
Flexible Spending Account Form
Use this form to enroll in the health and/or dependent care
flexible spending account program for the 2018 plan year.
Life Insurance Enrollment Form
Use this form to apply for supplemental life & AD&D coverage.
Life Insurance: Evidence of Insurability Form
Attach this form to the Life Insurance Enrollment form if you did
not elect supplemental life, AD&D insurance within 30 days of
hire. (Election beyond 30 days is subject to insurer approval).
Other Forms - Other forms like Beneficiary Designation and
457 deferral change forms are available via this link.
CASH-IN-LIEU FORMS
The cash in lieu incentive is available to COA, Council, Unrepresented Management and SMA
employees who waive enrollment in a medical plan. PSOA cash in lieu is closed to new
participation. Please contact the Department of Human Resources to obtain a form.
SUMMARIES OF BENEFITS AND COVERAGE
Copies of each medical plan’s Summaries of Benefits and Coverage can be found here: