You can now fill out forms online!  You must fill out required fields before printing and signing these forms (required fields are bordered in red).   
 

Please submit forms through interoffice mail/USPS mail to:

West Covina Unified School District-Business and Fiscal Services
Attn: Certificated Health Benefits -or- Classified Health Benefits
1717 West Merced Avenue
West Covina, CA 91790

You may also submit your forms in person. Supporting documents must be attached (i.e. marriage license, birth certificates, proof of coverage, etc.). 
 

Health Insurance Forms

• Medical    CalPERS Medical Form (HBD-12)              
                    CalPERS Medical Form (HBD-12a)
• Dental      Delta Dental of California Form
• Vision       Vision Service Plan Form
• Life           Hartford Life Insurance Beneficiary Form

Proper documentation is required to enroll any new dependents.

Opt-Out Program

• 2012-13 Medical Opt-Out Program Form

Section 125 Cafeteria Plan

• 2012-13 Section 125 Cafeteria Plan Form
• MasterCard Request Form
• P&A Direct Deposit Form
• P&A Reimbursement Claim Form
• P&A Dependent Care Election Form   

Employees interested in changing their health enrollments, enroll in the Medical Opt-Out Program, and/or participate in the Section 125 Cafeteria Plan, must do so during the Open Enrollment Period.  Employees may add/delete dependents to their exisitng health plan during the plan year if they experience a qualifying event.