District Benefits: Faculty Regular Full-Time & Part-Time Employees
Note: If you need to make changes due to a qualifying life event please contact Jim Firth, Human Resources Technician Benefits at ext. 6101 or firstname.lastname@example.org.
2020/2021 Online Open Enrollment:
Your Open Enrollment window is August 8, through August 25.
We are encouraging every employee to use the new online Open Enrollment Form this year. This form is a quick and easy way for you to select your benefits for the 2020/2021 benefit year. Most employees will not need to submit any other documentation.
Health Plan Election Form:
- 2020-2021 Faculty Health Plan Election Form
- 2020-2021 Faculty Couples Rate Health Plan Election Form: both spouses or Domestic Partners must be enrolled in a SISC Composite rate plan to qualify.
- For reference only: 2019-2020 Faculty Health Plan Election Form
- SISC Membership Change Form
- SISC III Enrollment Form
- SISC Kaiser Enrollment Form
- SISC Digital Signature Instructions
- SISC WABE Waiver of Benefits Form
- SISC HIPPA Notice of Privacy
- SISC COBRA Notice
- Notice: Medical Insurance Benefits Provided to Domestic Partners as Taxible Income
- Domestic Partnership Affidavit Termination
Faculty SISC Benefit Matrix:
Faculty Benefit Plans:
- Blue Cross PPO: 40463A - 100-A 20 Rx 5-20
- Blue Cross PPO: 40463B - 100-B 20 Rx 5-20
- Blue Cross PPO: 40463C - 80-C 20 Rx 5-20
- Blue Cross PPO: 40463D - 80-K 30 Rx 9-35
- Kaiser HMO: 225543-1018 - OV 10 Rx 10
- Kaiser HMO: 225543-1019 - OV 20 Rx 10-20
- Navitus Plan Information
- Delta Dental 1: 7079 1300 - DD 2000; C 100/1500
- Delta Dental 2: 7079 1350 - PPO 1500
- VSP: 2606681A - Signature C 5