PARTY STATE SHARESection 6. EMPLOYEE orCOBRA BARGAINING 9. TOTAL 4. PAY DED. CODE AMOUNT PERIOD COBEN DEDUCTION CSU-150 MONTH NON-CSU-351 COMPLETE ON CHANGES ONLY 10. STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES Reset Form DENTAL PLAN ENROLLMENT AUTHORIZATION D Print Form STD. Failure to provide the mandatory information may result in the dental enrollment action not being processed or being processed incorrectly. COBRA - ENROLLING IN COBRA CONTINUATION COVERAGE Complete Sections A B D and E 2. NAME First Middle Last ACTION CODE LIST ALL PERSONS TO BE ENROLLED IN DENTAL PLAN Include self First DATE OF BIRTH FAMILY RELATIONSHIP MM/ DD/ YY GENDER ADDRESS Number and Street City State and Zip SSN 4. EFFECTIVE 15. AGENCY 16. UNIT CODE 17. AGENCY NAME OR RETIREMENT SYSTEM IF RETIRED MONTH DAY YEAR 18 REMARKS PREMIUM AGENCY CALPERS RETIREE 19. SIGNING PERSONNEL OFFICER S NAME Please Print 20. AUTHORIZED AGENCY SIGNATURE I hereby certify under penalty of perjury as follows Th....
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How to fill out the CA STD. 692 online
The CA STD. 692 is a vital document used for dental plan enrollment in California. This guide offers clear, step-by-step instructions to assist users in completing the form accurately and efficiently online.
Follow the steps to complete the CA STD. 692 online successfully.
- Click the ‘Get Form’ button to access the CA STD. 692 and bring it up in the online editor.
- In Section A, enter your name clearly. Ensure you fill in both your first and last names.
- In Section B, specify the type of action you are taking: whether you are enrolling in a new plan, cancelling a plan, or changing your plan or dependent coverage. Complete the appropriate sections based on your selection.
- If you are enrolling or changing coverage, list all family members currently enrolled, as well as any to be added or deleted in the designated area. Indicate the action code next to each name.
- Complete the personal information fields, including address, social security number, marital status, and gender, making sure to adhere to the people-first language.
- In Section C, provide the name of your prior dental plan only if you are making a cancellation or change.
- In Section D, choose whether you wish to enroll in a dental plan or not. Sign and date the form in the designated areas, ensuring that your signature is clear.
- After filling out all necessary sections, review the form for accuracy. Once confirmed, you can save changes, download the completed form, print it for your records, or share it as necessary.
Complete your CA STD. 692 online to ensure your dental coverage is processed without delay.
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