Menchie Braza
Employee Benefits Technician
mbraza@glendale.edu
818-240-1000 , Ext. 5139

 

Link to Human Resources page for more information on Benefits, Policies and Handbooks

 

Form/Link description

Blue Shield Change Request Form (pdf)

To request changes for employee or dependent, such as address, SSN, date of birth, marital status, etc.

Blue Shield Enrollment Form - (pdf)

Application for enrollment to Blue Shield Medical Plan.

Blue Shield Statement of Claim Form (pdf)

To be used when the service provider has not submitted your claim directly to Blue Shield.
Cigna - Beneficiary Designation Form - Basic Life Insurance For designation of primary and contingent beneficiaries.
Cigna - Beneficiary Designation Form - Voluntary Accident Insurance     For designation of primary and contingent beneficiaries.
Cigna - Beneficiary Designation Form - Voluntary Term Life Insurance For designation of primary and contingent beneficiaries.
Dependent Care Reimbursement take care by WageWorks - To request reimbursement of dependent care expenses.

Delta Dental Information

General information on coverage and on-line access to your personal information.
Direct Deposit Request Log into take care by WageWorks and complete your request on-line.  Contact Menchie Braza if you have any questions.

Kaiser Acct Change Form 

For changes in name, address and phone number as well as adding or deleting dependents.
Medical Reimbursement  take care by WageWorks - To request reimbursement of medical expenses.
Opt-out of Medical Coverage Form for January to December Request to opt-out of District medical coverage and receive a monthly stipend for the period of January - December. Submit form to Menchie Braza in Employee Benefits.

 

 

 

 

 

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Last updated: 1/23/2015 2:31:30 PM