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Get CA STD. 692 2021-2024

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 That I am the duly appointed qualified and acting officer of the herein named agency and that I am authorized to make this certification that the employees named herein is eligible for enrollment in the State Dental Insurance Program. 21. DATE SIGNED 2. EMPLOYEE S OR ANNUITANT S SIGNATURE See Privacy Information on reverse of employee copy E FOR AGENCY OR RETIREMENT SYSTEM USE ONLY - Personnel5. PROVIDER/FACILITY NUMBER If applicable prepaid plans only CANCEL - Complete Sections A C D and E CHANGE - CHANGING PLANS OR DEPENDENT COVERAGE Complete Sections A B C D and E 3. ENTER THE ACTION CODE A ADD AND/OR D DELETE BESIDES THE NAMES OF ONLY THOSE MEMBERS TO BE ADDED OR DELETED. MARITAL STATUS 3. CHECK IF PERMANENT INTERMITTENT EMPLOYEE MARRIED 5. SEX SINGLE MALE DOMESTIC PARTNER 6. TELEPHONE NUMBER Include Area Code 23. EMAIL ADDRESS Distribute one copy each to Controller Carrier Agency and Employee 22. 17 and the Federal Privacy Act Public Law 93-579 require that this notice be provided when collecting personal information from individuals. The State Controller s Office requires employee s social security number and name for identification purposes. Legal references authorizing maintenance of this information include Government Code Sections 1151 1153 Sections 6011 and 6051 of the Internal Revenue Code and Regulation 4 Section 404. 1256 Code of Federal Regulations under Section 218 Title II of the Social Security Act. Information provided on the form will be forwarded to the dental insurance company providing coverage for the employee. The State Controller s Office requires employee s social security number and name for identification purposes. Legal references authorizing maintenance of this information include Government Code Sections 1151 1153 Sections 6011 and 6051 of the Internal Revenue Code and Regulation 4 Section 404. Legal references authorizing maintenance of this information include Government Code Sections 1151 1153 Sections 6011 and 6051 of the Internal Revenue Code and Regulation 4 Section 404. 1256 Code of Federal Regulations under Section 218 Title II of the Social Security Act. Information provided on the form will be forwarded to the dental insurance company providing coverage for the employee.

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