Menchie Braza
Employee Benefits Technician
mbraza@glendale.edu
818-240-1000 , Ext. 5139

 

Link to Human Resources page for more information on Benefits, Policies and Handbooks

 

Form/Link description
403(b) CalSTRS Venders List of 403(b) venders provided by the L.A. County Office of Education (LACOE)
403(b) and 457(b) Salary Reduction Agreement To establish, change or cancel salary reductions withheld from your paycheck and contributed to the 403(b) or 457(b) plan of your choice.

Blue Shield Change Request Form

To request changes for employee or dependent, such as address, SSN, date of birth, marital status, etc.

Blue Shield Enrollment Form - (pdf)

Application for enrollment to Blue Shield Medical Plan.
Blue Shield HMO Benefit Summary and Prescription Drug Coverage Information on Blue Shield HMO and prescription drug coverage.
Blue Shield PPO Benefit Summary and Prescription Drug Coverage Information on Blue Shield PPO and prescription drug coverage. 

Blue Shield Statement of Claim Form

To be used when the service provider has not submitted your claim directly to Blue Shield.
Cigna Beneficiary Designation Forms for Basic Life Insurance, Voluntary Term Life Insurance and Voluntary Accident Insurance For designation of primary and contingent beneficiaries for Cigna insurance.

Delta Dental Information

General information on coverage and on-line access to your personal information.
Kaiser Benefit Highlights for 2016 List of patient co-pays for visits, exams, prescription drug coverage, etc.

Kaiser Enrollment/Change Form 

For enrollment, changes in name, address and phone number as well as adding, changing or deleting dependents.
Opt-out of Medical Coverage Form for January to December 2016 Request to opt-out of District medical coverage and receive a monthly stipend for the period of January - December. Submit form to Menchie Braza in Employee Benefits.
Take Care by WageWorks - Dependent Care Reimbursement To request reimbursement of dependent care expenses. Requests can be submitted online.
Take Care by WageWorks - Medical reimbursement To request reimbursement of medical expenses. Requests can be submitted online.
Take Care by WageWorks - Direct Deposit Request Form To have your reimbursement deposited to your bank account, complete this form and submit to Menchie Braza in Employee Benefits. 

 

 

 

 

 

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Last updated: 2/17/2016 11:27:07 AM