Health Benefit Forms

Below are the health benefit enrollment forms for new full-time employees and for current full-time employees who would like to make changes to their health benefit enrollment. 

To make changes during Open Enrollment, please refer to the forms listed on the Open Enrollment website. 

Forms for New Full-time Employees

REQUIRED FORMS: 

1. Complete the electronic New Employee Health Benefits Enrollment form. 

    • If you already have your Cerritos network account, log into the SSO Portal and then use the link below:

New Employee Health Benefits Enrollment Form (SSO)

    • If you do not have a Cerritos network account yet, use the link below*: 

New Employee Health Benefits Enrollment Form (Non-SSO)

*Important: You will need to select “Create New Account” and follow the steps to create an account with your personal email address. Once you create your account, click the form link again and select “Complete New Form”. 

2. Complete the life insurance form. 

VOLUNTARY BENEFIT PLANS: 

  •  
    • Section 125 Flexible Spending Plans
      • Make an appointment with American Fidelity to enroll within 30 days of your start date by contacting:

Peter Morse, Sr. Account Manager
peter.morse@americanfidelity.com , (951) 600-0122
-or

Phyllis Scotton
Phyllis.scotton@americanfidelity.com , (949) 310-8949

    • Tax Shelter Annuity Contributions
      • Initiate contracts with TSA companies and their agents, found on the Payroll website.

FORMS FOR HEALTH BENEFIT PLAN CHANGES

The following forms should only be used for benefit plan changes outside of the annual open enrollment period. 

Medical, Dental, & Vision

Employees with a qualifying event that impacts their health benefit enrollment (such as divorce or the birth of a baby) can make changes using the Change in Employee Health Benefits Enrollment Form. 

Life Insurance Beneficiary Change

Complete the Life Insurance Beneficiary Change Form to change the beneficiary you have on file. 

Legal/ID Shield

Submit the Employee Benefit Member Application to sign up for legal and/or ID shield services.