Form Calhr 695 PDF Details

The State of California's Department of Human Resources provides a crucial bridge for retirees transitioning from active employment to retirement, particularly regarding the continuation of vision benefits, through the CalHR 695 form. This document, integral for the enrollment into the Retiree Vision Plan, necessitates precise and clear information from the retiree, ranging from basic identifiers to the decision on dependent coverage. The retiree is required to provide personal details, including social security number, date of birth, and contact information, aside from specifying the type of action, namely new enrollment. The form further accommodates the inclusion of dependents, provided they are eligible and duly authorized, underscoring the plan’s reach beyond the retiree to their immediate family members. A significant portion of the form relates to the authorization for deductions from the retirement warrant to cover the enrollee's share of the cost, highlighting the financial implications and the ongoing nature of the agreement, with a minimum commitment of 12 months. On a broader scale, the form encapsulates a privacy notice informed by both state and federal laws, emphasizing the confidentiality and governance over the use of the personal information provided. This dual focus on enrollment procedure and privacy safeguards reflects a comprehensive approach towards managing retiree benefits, making the CalHR 695 form a critical step in ensuring continued vision care for California's retired state employees and their families.

QuestionAnswer
Form NameForm Calhr 695
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescalhr695, calhr form 695 pdf, calhr 695, printable form cal hr 695

Form Preview Example

New Enrollment

State of California - Department of Human Resources

RETIREE VISION PLAN ENROLLMENT AUTHORIZATION

CalHR 695 (Rev 6/20/2012) Page 1

 

 

 

 

 

 

 

 

RV

 

Please type or use ballpoint pen, print clearly - send completed forms to vision plan vendor.

 

 

See General Terms of Enrollment and Privacy Statement on back.

 

 

 

 

 

 

 

 

 

 

Section A - Retiree Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name: Last

 

 

First

 

 

 

 

 

 

 

MI

 

 

 

 

 

Social Security Number

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Action

Mailing Address

(Number and Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Enrollment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section B - Dependent Information (if no dependents, skip Section B and go to Section C)

Name

 

Relationship

 

Social Security Number

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If more dependents, attach additional pages; only eligible, authorized dependents may use the plan.

Section C - Enrollment Election

I elect to enroll in a vision plan as shown above and authorize deduction to be made from my retirement warrant by my retirement system to cover my share of the cost of enrollment as it is now or may be in the future.

Furthermore, the vision plan vendor is authorized to transmit and my retirement system is authorized to accept enrollment data from the vision plan vendor. My retirement system shall consider my appearance on enrollment data in any form from the vision plan vendor as my authorization and agreement to initiate and make continuing deductions from my retirement warrant for payment of premiums for a minimum 12 month period. I understand that depending on the enrollment date, my enrollment period may be greater than 12 months

I do not wish to enroll into the Retiree Vision Plan.

I have read and understand the general terms of enrollment. (See reverse side - page 2):

Retiree's Signature

Date Signed

Section D (For Employing Agency Use only)

1. Deduction

 

 

3.Retiree Premium

 

4. Effective Date of Enrollment:

 

 

 

5. BU/CBID at

 

 

 

2. Party Code:

 

 

Deduction Amount $

 

 

 

 

 

 

Retirement:

 

 

 

Code: 475

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.Permitting

 

 

7. Permitting Event Code

 

 

8. Agency Name:

 

 

 

Unit Code:

 

Agency Code:

 

 

Event

 

 

50

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.Remarks

New Enrollment - Retiring From State:

Separation Date: Retirement Date:

10.Agency Telephone Number:

11.Date of

Agency

Signature:

12. I hereby certify under penalty of perjury as follows: That I am

the duly appointed, qualified and acting officer of the herein named agency and that I am authorized to make this the duly appointed, qualified and acting officer of the herein named agency and that I am authorized to make this certification; that the employee named herein is eligible for enrollment into the State Retiree Vision Plan.

Authorized Agency

Signature:

1 copy to Vendor 1 copy to Employing Agency 1 copy to Retiree/Annuitant

(6/2012)

State of California - Department of Human Resources

RETIREE VISION PLAN ENROLLMENT AUTHORIZATION

CalHR 695 (Rev 3/2012) Page 2

PRIVACY NOTICE

The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (Public Law 93-579) require that this notice be provided when collecting personal information from individuals. Information requested on this form is used by the vision plan vendor and the California Public Employees' Retirement System (CalPERS), Judges' and Legislators' Retirement Systems (JRS/LRS), the California State Teachers' Retirement System (CalSTRS), and the California State Military Retirement System (MRS) for the purposes of identification and insurance coverage processing. It is mandatory to furnish all information requested on this form except for employee's gender and marital status, which may be furnished on a voluntary basis and are used by the vision insurance company for statistical and actuarial purposes. Failure to provide the mandatory information may result in the vision insurance enrollment action not being processed or being processed incorrectly.

The State's contracted vision plan vendor and the CalPERS/JRS/LRS/CalSTRS/MRS require the retiree's/annuitant's social security number and name for identification purposes. Legal references authorizing maintenance of this information include Government Code Sections 1151 and 1153, Sections 6011 and 6051 of the Internal Revenue Code, and Regulation 4, Section 404.1256, Code of Federal Regulations under Section 218, Title II of the Social Security Act. Information provided on the form will be forwarded to the vision plan vendor providing coverage for the employee. Copies of the Retiree Vision Plan Enrollment Authorization are maintained in confidential files of the State's contracted vision plan vendor and with CalPERS/JRS/LRS/CalSTRS/MRS for five years. Employees have the right of access to copies of their Vision Plan Enrollment Authorizations upon request. Send requests to the vision carrier at: Vision Service Plan, Attn: Client Services MS 229, PO Box 997100, Sacramento, CA 95899-9986 or fax requests to: (916) 463.9031.

General Terms of Enrollment - Please read carefully:

Retirees/Annuitants enrolling into this program will be restricted to maintaining enrollment for a minimum period of 12 months. Length of enrollment may be greater depending upon when you enroll into the plan. A plan year runs from January 1 of any year through December 31 of the same calendar year. Employees retiring and enrolling into this program will be restricted to maintaining their enrollment for the balance of the plan year in which they enroll and must maintain enrollment for 12 months in the following plan year unless a permitting event occurs to change their enrollment. Permitting event policy is established by the plan administrator, California Department of Human Resources.

Only eligible dependents may be enrolled into this plan with the retiree/annuitant. Should you as the eligible retiree/annuitant enroll ineligible dependents, or otherwise maintain ineligible dependents on your plan, you may be held liable for the cost of any and all claims for services rendered. An ineligible dependent is any person you have enrolled onto your vision benefits plan or otherwise maintained on your vision benefits and is not considered an

eligible dependent under the enrollment rules of California Department of Human Resources. Should you have questions related to enrollment under this program, you may contact California Department of Human Resources at: (916) 323-2712.

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In order to complete this document, ensure you type in the information you need in each and every field:

1. The calhr 695 involves certain information to be typed in. Be sure the next blank fields are filled out:

Step # 1 for filling in calhr form 695

2. Once the previous array of fields is complete, you're ready insert the required details in I elect to enroll in a vision plan, Furthermore the vision plan vendor, I do not wish to enroll into the, I have read and understand the, Date Signed, Section D For Employing Agency Use, Code, Party Code, Retiree Premium Deduction Amount, Permitting Event Date, Permitting Event Code, Effective Date of Enrollment, BUCBID at Retirement, Agency Name, and Unit Code in order to go further.

Writing part 2 in calhr form 695

Be extremely attentive while filling in Agency Name and Effective Date of Enrollment, because this is the section where many people make a few mistakes.

3. The following section is about Retirement Date, Date of Agency Signature, I hereby certify under penalty of, Signature, and copy to Vendor copy to Employing - type in each one of these fields.

Filling out section 3 in calhr form 695

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