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Human Resources

Health & Welfare Benefits

Contact

Lisa Pendleton, Fiscal Assistant - Health & Welfare
Phone: (707) 279-1511 ext. 1032
Email: lpendleton@kvusd.org
Address: 4410 Konocti Road, Kelseyville, CA 95451

Basic Information Links

Health & Welfare- Contact Information

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Costco Mail Order

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Medical Temporary ID Card

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Medical Enrollment Form

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Medical Change Form (add/remove dependents and change name or address)

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Delta Dental Election Form

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Delta Dental Phone App

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Basic Life/AD&D Insurance Enrollment Form

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Payroll Address Name Change

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SISC Flex Plan Online Enrollment Instructions

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Flex Plan Enrollment

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Flex Plan Change Form

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Basic Life/Voluntary Life Change Form

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Voluntary Term Life Insurance Enrollment Form

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Dependent Eligibility Documentation Chart

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Proof of Death Claim Form

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Envoy Retirement Savings Plan - 403B

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Certificated Benefit Plans

New Enrollment

Certificated Plan Election Form

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Medical Claim Form

View Medical Claim Form.

Anthem Blue Cross Plan Description

Plan 40691C (90C)

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Plan 40691B (90E)

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Plan 40691D (80G)

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Plan 40728A (80K)

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Plan 40728B (Minimum Value Plan)

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Plan 70691B (2-Tier Anchor Bronze, No Dental/Vision

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Dental Plan Descriptions

Dental 7082-1210 (Premier Incentive Unlimited)

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Dental 7082-1225 (PPO $1500 Maximum) 

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Vision Plan Descriptions

Vision 2499570A (VSP Signature A $20)

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Classified Benefit Plans

New Enrollment

Classified Plan Election Form

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Medical Claim Form

View Medical Claim Form.

Anthem Blue Cross Plan Descriptions

Plan 40728C (100B)

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Plan 40691A (90C)

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Plan 40691E (80E)

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Plan 40691F (80K)

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Plan 70728B (2-Tier Anchor Bronze, No Dental/Vision/Life)

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Dental Plan Descriptions

Dental 7082-1010 (Premier Incentive Unlimited)

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Dental 7082-1021 (PPO $2000 Max)

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Vision Plan Description

Vision 2073591A (VSP Signature A $20)

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Life Insurance Plan Description

Group Life Insurance

Life Benefits Summary (Active Employee Only G00ABIH $100,000)

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Voluntary Life

Voluntary Term Life Insurance information

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Evidence of Insurability (for any additional life insurance above min. coverage)

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Unrepresented Benefit Plans

Plan Election Form

View Plan Election Form.

Medical Claim Form

View Medical Claim Form.

Anthem Blue Cross Plan Descriptions

Plan 40691J (100B)

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Plan 40691G (80G)

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Plan 40691H (80K)

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Plan 40691K (80M) 

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Plan 70692B (2-Tier Anchor Bronze, No Dental, No Vision)

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Dental Plan Descriptions

Dental 7082-1410 (Unlimited-No Ortho)

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Dental 7082-1610 (PPO $1500 Maximum)

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Vision Plan Description

Vision 2499556A (VSP Signature A $0/$25)

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Life Insurance Plan Description

Paid Life Insurance

Life Benefits Summary (Active Employee Only G00ABIH-65C $100,000)

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Voluntary Life

Voluntary Term Life Insurance Information

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Evidence of Insurability (for any additional life insurance above min. coverage)

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Upcoming Events

May 20

Early Dismissal Monday

All Day Event

May 20

State Testing

Start: May 20, 2024 End: May 31, 2024

Multi-Day Event

May 21

Regular Board Meeting

6:15 PM - 8:15 PM

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