Form STD.700 "Vision Plan Enrollment Authorization" - California

Form STD.700 Printable Pdf
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What Is Form STD.700?

This is a legal form that was released by the California Department of General Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2008;
  • The latest edition provided by the California Department of General Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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Download Form STD.700 "Vision Plan Enrollment Authorization" - California

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STATE OF CALIFORNIA — DEPARTMENT OF PERSONNEL ADMINISTRATION
V
PLEASE TYPE OR PRINT CLEARLY USING A BALLPOINT PEN
VISION PLAN ENROLLMENT AUTHORIZATION
SEND COMPLETED FORM TO PERSONNEL/PAYROLL OFFICE
STD. 700 (REV. 2/2008)
SEE PRIVACY NOTICE ON REVERSE OF EMPLOYEE COPY
SECTION A
1. ENROLLEE'S SOCIAL SECURITY NUMBER
6. DATE OF BIRTH
3. SEX
2. MARITAL STATUS
7. ACTION TYPE (Check one)
NEW--ENROLLING IN A PLAN FOR THE FIRST TIME
DOMESTIC PARTNER
SINGLE
MALE
FEMALE
MARRIED
A.
(Complete Sections A, B, and D)
4. NAME (First, Middle, Last)
COBRA - ENROLLING IN COBRA CONTINUATION COVERAGE
B.
(Complete Sections A, B, and D)
5. MAILING ADDRESS (Number and Street, City, County, State, Zip)
CANCEL--CANCELLING COVERAGE FOR ALL ENROLLEES
C.
(Complete Sections A, C, and D)
8. SPOUSE'S OR DOMESTIC PARTNER'S NAME (First, Middle, Last)
9. SPOUSE'S OR DOMESTIC PARTNER'S SOCIAL SECURITY NUMBER
10. DATE OF BIRTH
11. FAMILY MEMBER (First, Middle, Last)
12. RELATIONSHIP
13. SOCIAL SECURITY NUMBER
14. DATE OF BIRTH
15. FAMILY MEMBER (First, Middle, Last)
16. RELATIONSHIP
17. SOCIAL SECURITY NUMBER
18. DATE OF BIRTH
19. FAMILY MEMBER (First, Middle, Last)
20. RELATIONSHIP
21. SOCIAL SECURITY NUMBER
22. DATE OF BIRTH
SECTION B (Do not complete this Section if the Cancel box in Section A is checked)
2. PROVIDER/FACILITY NUMBER (If applicable)
1. NAME OF VISION PLAN BEING AUTHORIZED
SECTION C
1. NAME OF VISION PLAN BEING CANCELLED
SECTION D
1. CHECK APPROPRIATE BOX
A.
I do not wish to enroll in a vision plan. (Keep in employee's file)
I elect to enroll in a vision plan as shown above and authorize deductions to be made from my salary to cover my share of the cost of enrollment as
B.
it is now or as it may be in the future. I certify that I will only obtain vision services for myself and eligible dependents as defined by the State
of California. Any unauthorized use of these services by ineligible persons is a misuse of State funds.
C.
I elect to cancel the vision plan shown above.
DATE SIGNED
EMPLOYEE'S SIGNATURE (See Privacy Notice on reverse of employee copy.)
SECTION E (For agency use only)
8. BARGAIN­
7. EMPLOYEE
4. EMPLOYEE OR COBEN
5. STATE SHARE
6. EFFECTIVE DATE
1. EMPLOYER
2. VISION PLAN CODE
3. PARTY
ING UNIT
DESIGNATION
DEDUCTION
AMOUNT
OF ACTION
DED. CODE
ORG. CODE
CODE
AMOUNT
3
475
$
$
12. AGENCY
11. PERMITTING
13. UNIT CODE
10. PERMITTING
9. TOTAL PREMIUM
14. AGENCY NAME
CODE
EVENT CODE
EVENT DATE
AMOUNT
$
15. REMARKS
16.
CHECK HERE IF PERMANENT INTERMITTENT EMPLOYEE
17. AUTHORIZED AGENCY SIGNATURE
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 certification; that the employee named herein is
eligible for enrollment in the State Vision Insurance Program.
19. DATE RECEIVED
IN EMPLOYING
OFFICE
18. TELEPHONE NUMBER (Indicate if CALNET or give area code)
(MO.
DAY
YR.)
WHITE--TO CONTROLLER
PINK--TO AGENCY
GOLDENROD--TO EMPLOYEE
Clear
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STATE OF CALIFORNIA — DEPARTMENT OF PERSONNEL ADMINISTRATION
V
PLEASE TYPE OR PRINT CLEARLY USING A BALLPOINT PEN
VISION PLAN ENROLLMENT AUTHORIZATION
SEND COMPLETED FORM TO PERSONNEL/PAYROLL OFFICE
STD. 700 (REV. 2/2008)
SEE PRIVACY NOTICE ON REVERSE OF EMPLOYEE COPY
SECTION A
1. ENROLLEE'S SOCIAL SECURITY NUMBER
6. DATE OF BIRTH
3. SEX
2. MARITAL STATUS
7. ACTION TYPE (Check one)
NEW--ENROLLING IN A PLAN FOR THE FIRST TIME
DOMESTIC PARTNER
SINGLE
MALE
FEMALE
MARRIED
A.
(Complete Sections A, B, and D)
4. NAME (First, Middle, Last)
COBRA - ENROLLING IN COBRA CONTINUATION COVERAGE
B.
(Complete Sections A, B, and D)
5. MAILING ADDRESS (Number and Street, City, County, State, Zip)
CANCEL--CANCELLING COVERAGE FOR ALL ENROLLEES
C.
(Complete Sections A, C, and D)
8. SPOUSE'S OR DOMESTIC PARTNER'S NAME (First, Middle, Last)
9. SPOUSE'S OR DOMESTIC PARTNER'S SOCIAL SECURITY NUMBER
10. DATE OF BIRTH
11. FAMILY MEMBER (First, Middle, Last)
12. RELATIONSHIP
13. SOCIAL SECURITY NUMBER
14. DATE OF BIRTH
15. FAMILY MEMBER (First, Middle, Last)
16. RELATIONSHIP
17. SOCIAL SECURITY NUMBER
18. DATE OF BIRTH
19. FAMILY MEMBER (First, Middle, Last)
20. RELATIONSHIP
21. SOCIAL SECURITY NUMBER
22. DATE OF BIRTH
SECTION B (Do not complete this Section if the Cancel box in Section A is checked)
2. PROVIDER/FACILITY NUMBER (If applicable)
1. NAME OF VISION PLAN BEING AUTHORIZED
SECTION C
1. NAME OF VISION PLAN BEING CANCELLED
SECTION D
1. CHECK APPROPRIATE BOX
A.
I do not wish to enroll in a vision plan. (Keep in employee's file)
I elect to enroll in a vision plan as shown above and authorize deductions to be made from my salary to cover my share of the cost of enrollment as
B.
it is now or as it may be in the future. I certify that I will only obtain vision services for myself and eligible dependents as defined by the State
of California. Any unauthorized use of these services by ineligible persons is a misuse of State funds.
C.
I elect to cancel the vision plan shown above.
DATE SIGNED
EMPLOYEE'S SIGNATURE (See Privacy Notice on reverse of employee copy.)
SECTION E (For agency use only)
8. BARGAIN­
7. EMPLOYEE
4. EMPLOYEE OR COBEN
5. STATE SHARE
6. EFFECTIVE DATE
1. EMPLOYER
2. VISION PLAN CODE
3. PARTY
ING UNIT
DESIGNATION
DEDUCTION
AMOUNT
OF ACTION
DED. CODE
ORG. CODE
CODE
AMOUNT
3
475
$
$
12. AGENCY
11. PERMITTING
13. UNIT CODE
10. PERMITTING
9. TOTAL PREMIUM
14. AGENCY NAME
CODE
EVENT CODE
EVENT DATE
AMOUNT
$
15. REMARKS
16.
CHECK HERE IF PERMANENT INTERMITTENT EMPLOYEE
17. AUTHORIZED AGENCY SIGNATURE
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 certification; that the employee named herein is
eligible for enrollment in the State Vision Insurance Program.
19. DATE RECEIVED
IN EMPLOYING
OFFICE
18. TELEPHONE NUMBER (Indicate if CALNET or give area code)
(MO.
DAY
YR.)
WHITE--TO CONTROLLER
PINK--TO AGENCY
GOLDENROD--TO EMPLOYEE
STATE OF CALIFORNIA — DEPARTMENT OF PERSONNEL ADMINISTRATION
VISION PLAN ENROLLMENT AUTHORIZATION
STD. 700 (REV. 2/2008) (REVERSE)
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 State Controller's Office and the vision insurance
company 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 Controller's Office requires employee'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 insurance company providing
coverage for the employee. Copies of the Vision Plan Enrollment Authorization are maintained in
confidential files of the State Controller's Office for five years. Employees have the right of access to
copies of their Vision Plan Enrollment Authorizations upon request. Send requests to: State
Controller's Office, Personnel/Payroll Operations Bureau, P.O. Box 942850, Sacramento, California
94250-5878, Attention: Benefits Unit.
California Department of General Services California Legal Forms United States Legal Forms

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Form STD.700 Printable Pdf
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