HEALTH and SAFETY and BENEFITS FORMS

Please note: most of these forms are for reference only, and you must contact the Health and Safety or Benefits Department for an actual copy.

ADA Forms
ADA Form A
ADA Form B
ADA Form C
ADA Form D

DMV Forms
Cart Safety Rules
Driver Data Form

Dental Insurance Forms
Delta Premier Plan Document
Delta PMI Enrollment/Change Form
Delta Premier Enrollment/Change Form

Financial Forms
403(b)/457 Tax Sheltered Annuity Form (Salary Reduction Agreement)
Direct Deposit Form

Health Insurance Forms
Medical Universal Enrollment/Change Form
WageWorks URM Claim Form
WageWorks DDC Claim Form
UnitedHealthCare Claim Form
AFLAC Direct Deposit Form

AFLAC Accident Claim Form
AFLAC Disability Claim Form
AFLAC Sickness Claim Form
Kaiser Enrollment/Change Form
Kaiser Emergency Claim Form

Life Insurance Forms
Application for Accidental Death Benefits
Enrollment/Application for Group Life Insurance
Designation of Beneficiary
Group Life Claim Form
Voluntary ADD Insurance Enrollment Form
Voluntary Life Insurance Overview

Long Term Disability Forms
LTD Plan Document for Classified Employees and Contracted Certificated Employees with LESS than 5 years of service in CalSTRS
LTD Plan Document for Contracted Certificated Employees with 5 or MORE years credited service in CalSTRS
Application for Long Term Disability Income Benefits

Leave of Absence Forms
Request for Leave of Absence Form
Health Care Provider Certification Form

Property and Casualty Forms
Claim Against GCCCD Form

Retirement Forms

3121 Beneficiary Form
3121 Address Change Form
3121 Distribution/Rollover Form

Safety Forms
Record of Employee Safety Training

Workers' Compensation Forms
District Injury/Illness report
Employee Claim form, California DWC
Employer's Report of Occupational Injury, form 5020
Guidelines, California DWC
Instructions for Filing a Claim - Quick Reference
Map to ALL other Sharp Occupational Medicine Facilities
Map to Sharp Rees Stealy in La Mesa
MPN Pamphlet
Predesignation Form (DWC Form 9783)

Worker Comp Benefits

  • GCCCD
  • Grossmont
  • Cuyamaca
Grossmont-Cuyamaca Community College District