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. (Form takes a while to load.)

Delta Dental Information

General information on coverage and on-line access to your personal information.
Direct Deposit Request form take care by WageWorks - If you had a Direct Deposit agreement with AFLAC for medical or dependent care reimbursements, it will automatically be transferred to WageWorks. (Form takes a while to load.)

Kaiser Acct Change Form - pdf (Benefits)

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. (Form takes a while to load.)
Opt-out of Medical Coverage Form for January to December 2014 Request to opt-out of District medical coverage and receive a monthly stipend for the period of January - December 2014. Submit form to Menchie Braza in Employee Benefits.

 

 

 

 

 

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Last updated: 1/7/2014 3:32:03 PM