10-08-2025, 08:42 AM
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 - Permanent Intermittent: Indicate if the employee is Permanent- Intermittent
Section - Remarks: Complete this section to provide additional information to clarify the action being taken. If the fax lists 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.
![[Image: fax-lists-4.png]](https://i.postimg.cc/J7YWZKLT/fax-lists-4.png)
Section - Authorized Agency Signature: 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 Agency Signature". Use the CALNET number if the Personnel Office is outside the Sacramento area.
STD R - Reimbursement Account Enrollment
Instructions to assist employees in completing Sections - are contained in the FlexElect Handbook. The Personnel Office should review each enrollment form to ensure it has been completed correctly. The Personnel Office should then complete the remainder of the form, Sections - Specific instructions for completion of the form are outlined below:
Section - Enrollment:
If employees are:
enrolling during the annual open enrollment period, check Item A.
enrolling as "newly eligible" (i.e. enrolling during a non-open enrollment period due to a permitting event), check Item B.
changing their enrollment because they have experienced a valid change in status event (permitting event), check Item C.
cancelling their enrollment as the result of a valid change in status event, check Item D.
electing to continue their MRA via COBRA, check item E.
Section - Total Monthly Amount to be Deducted: Amounts are withheld from the employee's paycheck and deposited in the appropriate account
A: Indicate the monthly Medical Reimbursement Account deduction.
B: Indicate the monthly Dependent Care Reimbursement Account deduction.
.
Section - SCO Use Only: Section - Important Program Information and Employee Signature/Date: This section contains important information that employees should be aware of when enrolling in FlexElect. Their signatures certify that they have other medical and/or dental coverage and that they have read the information and agree to the terms and conditions of the Program as outlined on the Reimbursement Account Enrollment Authorization (STD. R) and in the FlexElect Handbook.
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 - Permanent Intermittent: Indicate if the employee is Permanent- Intermittent
Section - Remarks: Complete this section to provide additional information to clarify the action being taken. If the fax lists 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.
Section - Authorized Agency Signature: 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 Agency Signature". Use the CALNET number if the Personnel Office is outside the Sacramento area.
STD R - Reimbursement Account Enrollment
Instructions to assist employees in completing Sections - are contained in the FlexElect Handbook. The Personnel Office should review each enrollment form to ensure it has been completed correctly. The Personnel Office should then complete the remainder of the form, Sections - Specific instructions for completion of the form are outlined below:
Section - Enrollment:
If employees are:
enrolling during the annual open enrollment period, check Item A.
enrolling as "newly eligible" (i.e. enrolling during a non-open enrollment period due to a permitting event), check Item B.
changing their enrollment because they have experienced a valid change in status event (permitting event), check Item C.
cancelling their enrollment as the result of a valid change in status event, check Item D.
electing to continue their MRA via COBRA, check item E.
Section - Total Monthly Amount to be Deducted: Amounts are withheld from the employee's paycheck and deposited in the appropriate account
A: Indicate the monthly Medical Reimbursement Account deduction.
B: Indicate the monthly Dependent Care Reimbursement Account deduction.
.
Section - SCO Use Only: Section - Important Program Information and Employee Signature/Date: This section contains important information that employees should be aware of when enrolling in FlexElect. Their signatures certify that they have other medical and/or dental coverage and that they have read the information and agree to the terms and conditions of the Program as outlined on the Reimbursement Account Enrollment Authorization (STD. R) and in the FlexElect Handbook.