You are eligible for vision benefits once each calendar year.
Type of action: New Enrollment, COBRA, Change or Cancel.
Open enrollment: the form is marked not for open enrollment use.
Dependents: if more dependents, attach additional pages; only eligible, authorized dependents may use the plan.
Ineligible dependents: an eligible employee who enrolls ineligible dependents may be held liable for the cost of any and all claims for services rendered.
Plan year: a plan year runs from January 1 of any year through December 31 of the same calendar year.
| Question | Answer |
|---|---|
| Form Name | CalHR 774 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 68 |
| Avg. time to fill out | 12 min |
| Edition | Rev 3/2024 |
| Issuing agency | California Department of Human Resources |
| Where to send | VSP, Attn: Client Administrative Services, MS 422, PO Box 997100, Sacramento, CA 95899-7100; email stateofca@vsp.com; fax 916.389.8304 |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | CalHR 774, CalHR774, CalHR 774 form, Premier Vision Plan Enrollment, Premier Vision Plan Enrollment Authorization |
| Official source | CalHR 774 (Rev 3/2024), California Department of Human Resources |
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