Benefits Forms
Forms requiring your signature need to be mailed to the address below:
Montebello Unified School District
Payroll & Benefits Department
123 S. Montebello Blvd.
Montebello, CA 90640
General Documents for all Employees
Self-Insured Schools of California (SISC III)
Forms For All Eligible Employees
•2021 Health Benefit Payroll Deductions
•CalPERS 2021 Summary Comparison
•Affidavit of Parent Child Relationship
• CALPERS Health Benefit Enrollment Form (Employees)
• CALPERS Health Benefit Enrollment Form (Retirees)
• Health & Welfare Contact Information
• Sheakley Change In Status Form
• Sheakley Dependent Care Claim Form
• Medical Waiver-Declaration of Health Coverage: HBD-12A
• Dental Insurance Waiver
• EASE Resources
• Long Term Care (UNUM)
• MetLaw Enrollment Form
• MetLife Dental Enrollment/Change Forms
• COBRA PERS Group Continuation Plan
• MetLife DHMO Booklet (updated 9/23/16)
• MetLife DHMO Enrollment Form (updated 9/23/16)
• MetLife DHMO Plan Rates (updated 9/21/16)
• MetLife Dental Expense Claim Form
• PrimeMail Prescription Order Form
• Proof of Death Claim Form
• Sheakley Healthcare Reimbursement Claim Form
• Sheakley Monthly Dependent Care Claim Form
• Vision Service Plan (VSP) Enrollment Form
• Waiver Form (MUSD Opt-Out Form) (updated 09/14/2020)
