Cafeteria Plan Forms for 2023 Health Plan Changes

Region 1- to see a full list of counties visit CalPERS. Please submit Cafeteria Plan forms ONLY if you are making changes to your enrollment or if you are enrolling for the first time. Flex dollar allowances and premium rates are for 2023, however since CalPERS requires prepayment of premiums, the scheduled rate increases go into effect in December of 2022 (for January 2023 coverage).

Executives, Mid-Mgmt & Electeds

• Exec., Mid-Mgmt & Electeds Cafeteria Plan Form

San Rafael Fire Chief Officers’ Association

• SRFCOA Cafeteria Plan Form

San Rafael Firefighters’ Association

• SRFA Cafeteria Plan Form

San Rafael Police Mid-Mgmt Association

• SRPMM Cafeteria Plan Form

San Rafael Police Association

• SRPA Cafeteria Plan Form

AFSCME/ Public Employees Local-1 Confidential Unit

• AFSCME/PEU Local 1- Cafeteria Plan Form

SEIU-  Local 1021

• SEIU- Local 1021 Cafeteria Plan Form

SEIU- Child Care

• SEIU- Child Care Cafeteria Plan Form

Western Council of Engineers

• WCE Cafeteria Plan Form

Fixed-Term employees

• Fixed-Term
• Fixed-Term (Exempt)

Additional resources: CalPERS website.