Section - Effective Date of Action:
The effective date of action during open enrollment is January For documents processed outside the open enrollment period refer to the effective date rule for the appropriate permitting event.
Section - Employee CBID: Indicate the employee's Collective Bargaining Designation and Unit.
Section - Permitting Event Date: Complete this section for newly eligible enrollments or allowable change requests due to a permitting event. The Permitting Event Date is the b2c datasets date when an employee experienced a valid change in status event (permitting event). Do not complete this area for open enrollment requests.
Section - Permitting Event Code:
Indicate the appropriate code as provided on Appendix A of this manual. enrollment change during the plan year due to a valid change in status event (permitting event). Do not complete this section for open enrollment requests.
Section - Health Form Attached (HBD-):
If employees are making any changes to their current medical insurance plan, attach the HBD- or Health Benefit and Enrollment History page after confirmation from my|CalPERS to the FlexElect enrollment form and check box "Yes". If employees are not making any changes to their current medical insurance plan, do not attach an HBD- or Health Benefit and Enrollment History page after confirmation from my|CalPERS to the FlexElect enrollment form and check box "No".
Section - Dental Form Attached (STD:
If employees are making any changes to their current dental insurance plan, attach the STD. to the FlexElect enrollment form and check box "Yes". If employees are not making any changes to their current dental insurance plan, do not attach a STD. to the FlexElect enrollment form and check box "No".
Section - Remarks: Complete this section to provide additional information to clarify the action being taken. If the employee is also enrolling in a reimbursement account(s), please indicate "STD. R attached".
Important Note: For new enrollments, describe the permitting event that makes the employee newly eligible.
Section Agency Name: Indicate the name of the employee's department or agency
SectionAuthorized Agency Signature: The signature of the individual in the Personnel Office who is authorized to complete the FlexElect enrollment form.Section Date Received in Employing Office: Indicate the date the FlexElect enrollment form was received in the employing office.
Section Telephone Number: Indicate the telephone number of the individual signing the "Authorized AgenSignatureUse the CALNET number if the Personnel Office is outside the Sacramento area.