Forms to complete firefighter oct 2017

SAN RAMON VALLEY FIRE PROTECTION DISTRICT Please complete the following forms and bring the completed forms with you to your scheduled onboarding meeting at the Administration Building: • Confidentiality Acknowledgement • HIPAA Agreement • U.S. DOB I-9 Form (Please also bring identification as listed on the back of the form) • EEO Data Form • W-4 and DE-4 Forms; Payroll “Notice” • Direct Deposit Authorization Form • General Emergency Contact/Dependent Information • Receipt for Administrative Policies Form Also attached are the District’s benefits forms and related information.

If you have any questions regarding the forms, please contact Erica Greenberg at (925) 838-6679.

September 14, 2017

Re: Employee Benefits Information Dear Employee: The following is a summary of the benefits offered by the San Ramon Valley Fire Protection District: 1.

Retirement Information (Contra Costa County Employees’ Retirement Association): •

2.

Health Benefits - Effective Dates: • • • • • •

3.

Enrollment Date – effective November 1, 2017 (First deduction will be reflected on your November 10th paycheck, covering the month of October.)

Life/AD&D coverage ($20,000.00 employee only) – effective November 1, 2017 Dental Insurance – effective October 1, 2017 Employee Assistance Plan – effective November 1, 2017 Medical Insurance – effective November 1, 2017 Vision Coverage – effective November 1, 2017 – and District’s self-funded supplemental vision plan Section 125 Plan – effective November 1, 2017 (optional)

Premium Costs: •

For Medical premiums, the following terms are effective January 1, 2014: ❖ The District contributes 92% of monthly premiums for employee and dependent medical up to an established cap, which is currently based upon the monthly premium for the second highest Bay Area health plan offered through CalPERS. The employee pays 8% of the monthly premium for their chosen health plan.

❖ Should the employee choose a health plan with monthly premiums above the established cap, the employee shall pay 8% of the second highest Bay Area health plan (cap) in addition to the premium difference between the cap and the chosen plan. ❖ The District cap plan is the second highest Bay Area health plan offered through CalPERS, regardless of the CalPERS region in which the employee resides. ❖ If the employee can provide evidence of current medical coverage under another plan, the employee may Opt-Out of District-sponsored medical coverage.

See Opt-Out information sheet and Medical Insurance Coverage Waiver Form.

•

For all dental, vision, and employee assistance plan premiums, under the current MOU, the District pays the premiums for District-provided benefits for the employee and any dependent(s) (if applicable).

•

For life insurance premiums, under the current MOU, the District pays the premium for the District-provided benefit for the employee only.

4. Enclosed Benefit Information/Forms and Reading Material: • • • • •

Contra Costa County Employee’s Retirement Association (CCCERA) – Retirement Benefit; Request for Reciprocity; other forms The Hartford (CNA) Insurance Companies – Group Life Insurance Sun Life Company – Summary of Benefits (Dental) Vision Service Plan (VSP) and the District’s self-funded plan (no enrollment forms required) Concern: EAP – Employee Assistance Plan (no enrollment form required)

5. Additional voluntary benefits and services available through the District: •

Deferred Compensation 457 Plans → ICMA (contact Chad Parilla, Retirement Specialist at 866-749-5177) → CalPERS (contact Tamika Workmon (at Voya) - (888) 713-8244, option 2 – Third Party Administrator → Nationwide Retirement Solutions (contact Jake Sours – Retirement Specialist at (916) 708-1320.

Please note, the above program is by employee contribution only, the District does not contribute.

•

Credit Unions → To join Contra Costa Federal Credit Union call (925) 335-3828 → To join Patelco Credit Union call (800) 358-8228

•

Long Term Care → California Association of Professional Firefighters (contact Carron Finley at 877582-0003, ext 6118)

→

California PERS (customer service number 800-908-9119)

•

Long Term Disability - Available through the Firefighters Association Local #3546. A form is enclosed if you wish to enroll (if you choose this plan, it will show up as Union Dues on your paycheck). Please note, the District does not participate in the State SDI program so there is no other disability insurance offered.

•

Benefit Administration Corporation – Section 125 Flexible Spending Account

Please fill out the enclosed forms and bring them with you to your scheduled orientation. If you have any questions, please do not hesitate to contact Erica Greenberg at (925) 838-6679.

Sincerely,

Paige Meyer Fire Chief Enclosures

USCIS Form I-9

Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

OMB No. 1615-0047 Expires 08/31/2019

â–şSTART HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name)

Apt. Number

Address (Street Number and Name)

Date of Birth (mm/dd/yyyy)

Middle Initial

First Name (Given Name)

U.S. Social Security Number -

Other Last Names Used (if any) State

City or Town

ZIP Code

Employee's Telephone Number

Employee's E-mail Address

-

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes): 1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident

(Alien Registration Number/USCIS Number):

4. An alien authorized to work

until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions) QR Code - Section 1 Do Not Write In This Space

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

OR 2. Form I-94 Admission Number:

OR 3. Foreign Passport Number: Country of Issuance: Signature of Employee

Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator.

A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Today's Date (mm/dd/yyyy)

Signature of Preparer or Translator Last Name (Family Name)

Address (Street Number and Name)

First Name (Given Name)

City or Town

State

ZIP Code

Employer Completes Next Page Form I-9 07/17/17 N

Page 1 of 3

USCIS Form I-9

Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

OMB No. 1615-0047 Expires 08/31/2019

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Employee Info from Section 1

Last Name (Family Name)

List A

First Name (Given Name)

OR

List B

M.I.

AND

List C

Identity

Identity and Employment Authorization

Citizenship/Immigration Status

Employment Authorization

Document Title

Document Title

Document Title

Issuing Authority

Issuing Authority

Issuing Authority

Document Number

Document Number

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Expiration Date (if any)(mm/dd/yyyy)

Expiration Date (if any)(mm/dd/yyyy)

Document Title QR Code - Sections 2 & 3 Do Not Write In This Space

Additional Information

Issuing Authority Document Number Expiration Date (if any)(mm/dd/yyyy) Document Title Issuing Authority Document Number Expiration Date (if any)(mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy): Signature of Employer or Authorized Representative Last Name of Employer or Authorized Representative

(See instructions for exemptions)

Today's Date (mm/dd/yyyy)

Title of Employer or Authorized Representative

First Name of Employer or Authorized Representative

Employer's Business or Organization Address (Street Number and Name)

City or Town

Employer's Business or Organization Name State

ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)

A. New Name (if applicable) Last Name (Family Name)

B. Date of Rehire (if applicable) First Name (Given Name)

Middle Initial

Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

Document Title

Document Number

Expiration Date (if any) (mm/dd/yyyy)

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative

Form I-9 07/17/17 N

Today's Date (mm/dd/yyyy)

Name of Employer or Authorized Representative

Page 2 of 3

LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. LIST A Documents that Establish Both Identity and Employment Authorization 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machinereadable immigrant visa 4. Employment Authorization Document that contains a photograph (Form I-766) 5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

LIST B

LIST C Documents that Establish Employment Authorization

Documents that Establish Identity OR

AND 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 3. School ID card with a photograph 4. Voter's registration card 5. U.S. Military card or draft record 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority

For persons under age 18 who are unable to present a document listed above:

1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION 2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240) 3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 4. Native American tribal document 5. U.S. Citizen ID Card (Form I-197) 6. Identification Card for Use of Resident Citizen in the United States (Form I-179) 7. Employment authorization document issued by the Department of Homeland Security

10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form I-9 07/17/17 N

Page 3 of 3

Form W-4 (2017)

The exceptions don't apply to supplemental wages greater than $1,000,000.

Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial

Basic instructions. If you aren't exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

situation changes.

Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or

Note: If another person can claim you as a dependent on his or her tax return, you can't claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.

Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below.

See Pub. 505 for information on converting your other credits into withholding allowances.

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: • Is age 65 or older,

• Is blind, or • Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

percentage of wages.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends,

consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.

Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married)."

Future developments. Information about any future developments affecting Form W-4 (such as legislafion enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)

Enter "1" for yourself if no one else can claim you as a dependent .................. A

• You're single and have only one job; or Enter "1" if: < • You're married, have only one job, and your spouse doesn't work; or ) . . . B • Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less.

Enter "1" for your spouse. But, you may choose to enter "-0-" if you are married and have either a working spouse or more than one job. (Entering "-0-" may help you avoid having too little tax withheld.) .............. c

D E F

Enter number of dependents (other than your spouse or yourself) you will claim on your tax return ........ D

Enter "1" if you will file as head of household on your tax return (see conditions under Head of household above) . . E Enter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit ... F (Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

G

Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter "2" for each eligible child; then less "1" if you have two to four eligible children or less "2" if you have five or more eligible children.

•If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter "1" for each eligible child. G Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) >• H For accuracy,

complete all worksheets

that apply.

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2.

• If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form

W-4

Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate ^ Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Your first name and middle initial

17

2 Your social security number

Last name

Home address (number and street or rural route)

0MB No. 1545-0074

3 II Single II Married II Married, but withhold at higher Single rate.

Note: If married, but legally separated, or spouse is a nonresident alien, check the "Single" box.

City or town, state, and ZIP code

4 If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card. > Q

Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) Additional amount, if any, you want withheld from each paycheck 7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and • This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write "Exempt" here . ............. .>\7 Under penalties'of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee's signature 0'his form is not valid unless you sign it.)

8 Employer's name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Date > 9 Office code (optional)

Cat.No.10220Q

10 Employer identification number (EIN)

Form W-4 (2017)

Form W-4 (2017)

Page 2

Deductions and Adjustments Worksheet Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1 Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce

your itemized deductions if your income is over $313,800 and you're married filing jointly or you're a qualifying widow(er); $287,650 if you're head of household; $261,500 if you're single, not head of household and not a qualifying widowfer); or $156,900 if you're married filing separately. See Pub. 505 for details ..................... 1 $_

$12,700 if married filing jointly or qualifying widow(er) 2 Enter: \ $9,350 if head of household } ........... 2 $

$6,350 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter "-0-" ................ 3 $

4 Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub.505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to WithholdingAllowances for 2017 Form W-4wo^sheet\n Pub. 505.} . ........... 5 $ 6 Enter an estimate of your 2017 nonwage income (such as dividends or interest) ........ 6 $ 7 Subtract line 6 from line 5. If zero or less, enter "-0-" ................ 7 $

8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction ....... 8 9 Enter the number from the Personal Allowances Worksheet, line H, page 1 ......... 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 -IQ

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1 .)

Note: Use this worksheet only if the instructions under line H on page 1 direct you here.

1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than"3"

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter "-0-") and on Form W-4, line 5, page 1. Do not use the rest of this worksheet .........

Note: If line 1 is less than line 2, enter "-0-" on Form W-4, line 5, page 1. Complete lines 4 through 9 below to

figure the additional withholding amount necessary to avoid a year-end tax bill.

Enter the number from line 2 of this worksheet .......... 4 Enter the number from line 1 of this worksheet .......... 5

Subtract line 5 from line 4 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here ....

Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .

Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck

Table 1 All Others

Married Filing Jointly If wages from LOWEST paying job are—

$0 7,001 14,001 22,001 27,001 35,001 44,001 55,001 65,001 75,001 80,001 95,001 115,001 130,001 140,001 150,001

$7,000 14,000 22,000 27,000 35,000 44,000 55,000 65,000 75,000 80,000 95,000 - 115,000 - 130,000 140,000 - 150,000 and over

Enter on line 2 above

If wages from LOWEST paying job are-

$0

10 11 12 13 14

9 $

Table 2

8,001 16,001 26,001 34,001 44,001 70,001 85,001 110,001 125,001 140,001

$8,000 16,000 26,000 34,000 44,000 70,000 85,000 - 110,000 - 125,000 - 140,000 and over

Married Filing Jointly Enter on line 2 above

0 1 2 3 4 5 6 7 8 9 10

If wages from HIGHEST paying job are— $0 - $75,000 75,001 - 135,000 135,001 - 205,000 205,001 - 360,000 360,001 - 405,000 405.001 and over

Enter on line 7 above

$610 1,010 1,130 1,340 1,420 1,600

All Others If wages from HIGHEST paying job are— $0 - $38,000 38,001 - 85,000 85,001 - 185,000 185,001 - 400,000 400.001 and over

Enter on line 7 above

$610 1,010 1,130 1,340 1,600

J5

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving It to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and Intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid 0MB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

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Social Security Administration

Statement Concerning Your Employment in a Job Not Covered by Social Security Employee Name

Employee ID#

Employer Name San Ramon Valley Fire

Employer ID#

68-0419453

Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected.

Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax.

As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall Elimination Provision.”

Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government Pension Offset.”

For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security Benefits.

Signature of Employee Form SSA-1945 (01-2013) Destroy Prior Editions

Date

Information about Social Security Form SSA-1945 Statement Concerning Your Employment in a Job Not Covered by Social Security New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not covered under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential effects of two provisions in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social Security benefit received as a spouse, surviving spouse, or an ex-spouse.

Employers must:

•

Give the statement to the employee prior to the start of employment;

• •

Get the employee’s signature on the form; and Submit a copy of the signed form to the pension paying agency.

Social Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/online/ssa-1945.pdf. Paper copies can be requested by email at ofsm.oswm.rqct.orders@ssa.gov or by fax at 410-965-2037. The request must include the name, complete address and telephone number of the employer. Forms will not be sent to a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.

Form SSA-1945 (01-2013)

SAN RAMON VALLEY FIRE PROTECTION DISTRICT DIRECT DEPOSIT AUTHORIZATION FORM I hereby authorize the Payroll Department to initiate an electronic transfer in the amount of net pay from my paychecks and deposit such amounts into the designated accounts below. I understand that the District does not guarantee timely availability of deposits. I also authorize the Payroll Department to make up adjustments for any erroneous credits. I also understand that transactions under this Authorization will be subject to the Federal Electronic Fund Transfer Act and to other applicable laws and regulations, and that the Financial Institution(s) in which my paycheck is deposited will provide me a statement as to my rights and obligations in connection with such transactions, in accordance with The Act. This Authorization is to remain in effect until the Payroll Department has received written notice from me of its termination, change, or until I terminate my employment or the direct deposit program is cancelled.

Employee Name (Print)

Badge #

Employee Signature:

Date:

Account Information: You may choose up to three accounts. Optional Accounts #2 and #3 must have a fixed amount. The residual net pay will be deposited into the primary account (Account #1).

Submit completed form along with voided check or bank form with Account and Routing/Transit Numbers.

Account #1 - Primary

□

Add

□

Change

□

Checking

□

Savings

□

Savings

□

Savings

Bank Name: Routing/Transit # (nine digits):

Account #:

I wish to deposit:

□ Entire Net Amount

Account #2 - Optional

□

Add

□

Change

□

Checking

Bank Name: Routing/Transit # (nine digits):

Account #:

I wish to deposit:

$

Account #3 - Optional

□

Add

□

Change

□

Checking

Bank Name: Routing/Transit # (nine digits): I wish to deposit:

Account #: $

SAN RAMON VALLEY FIRE PROTECTION DISTRICT PAYROLL NOTES FOR NEW HIRES 1. PAY DATES a. Monthly payroll on the 10th of each month for the prior month b. Optional advance payroll on the 25th of each month (Up to 1/3 of base monthly salary-signed form required) 2. PAYMENT OPTIONS/DELIVERY a. Direct deposit (maximum of (3) checking and (2) savings accounts) (Form required with voided checks and/or bank and account numbers) b. Live Check c. Delivery of paychecks/paystubs via pickup at Admin, mail or I Pay 3. TAX WITHHOLDING a. Federal Form W4 and EDD Form DE4 (optional) to declare federal and state income tax withholding b. Mandatory Medicare tax withholding of 1.45% c. Exempt from Social Security Tax withholding d. The District does not participate in CA Disability Plan (SDI) 4. DEDUCTIONS a. Retirement contribution (pre-tax) - Mandatory and based upon age at entry into the retirement system (reciprocity may be established) b. Union Dues, if Represented, contact Captain Korey Barragan for details c. Advance pay (if elected) will be deducted from your 10th paycheck d. 457 Deferred Compensation Contribution (if elected) e. Section 125 Plan Deductions (if elected for eligible dependent care or medical expenses) f. Long-Term Care Insurance (if elected) g. Care Group Contribution (if elected) h. Long-Term Disability Insurance (if elected - Non-represented employees = $22.50; appears as "Union Dues" on monthly paycheck) i. Medical Insurance (Employee pays 8% of their current monthly premium - see MOU for details) 5. LEAVE BENEFITS a. All leaves are tracked through our payroll system and the usage and ending balances will appear on your monthly paycheck on the 10th b. Sick Leave: for 56-hour personnel, 144 hours is advanced at hire and monthly accrual is 12 hours after one year; for 40-hour personnel, 96 hours is advanced at hire and monthly accrual is 8 hours after one year c. Vacation: for 56-hour personnel, accrual is 14 hours per month initially; for 40-hour personnel, accrual is 10 hours per month initially 6. OVERTIME a. Overtime is tracked through a customized program written in Microsoft Access b. You are responsible for entering a separate entry for each overtime occurrence The entry then gets routed for supervisor approval and on to payroll for processing c. For 56-hour suppression personnel, FLSA paid monthly to employees as a differential for 12.67 hours/month at one-half the employee's hourly rate For 56-hour dispatch personnel, FLSA paid monthly to employees as a differential for 70.00 hours/month at one-half the employee's hourly rate 7. OTHER REIMBURSEMENT a. Mileage reimbursement is processed through payroll and will appear as additional "net" cash on your paycheck, but will not be taxed as compensation b. Forms are available online or can be obtained at Admin and should be approved by your immediate supervisor before they are submitted to payroll c. Lodging for Educational Assistance is considered taxable earnings

Updated 8/14

SAN RAMON VALLEY FIRE PROTECTION DISTRICT SALARY ADVANCE REQUEST

I hereby request the Payroll Department to: 1. Advance to me on or about the 25th of each month, an amount equal to one-third (1/3) of my base monthly salary. 2. Advance to me on or about the 25th of each month, the amount specified below, which is less than one-third (1/3) of my monthly base salary.

DESIRED ADVANCE AMOUNT



__________________

 3. Discontinue my salary advance.

I understand if I receive a payroll advance, the District has the authority to adjust my payroll advance for each day I am absent without pay during the first fifteen days of any month.

______________________________________ Name

_________________ Emp. #

______________________________________ Signature

__________________ Date

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Form Enrollment Affidavit

101 (Rev. 2017)

Purpose of this form: Use this form to advise CCCERA that you are a new employee or a rehire that might be eligible for CCCERA membership.

NOTE: The original document must be submitted. Fax/Copies are not accepted.

Additional forms for employee:  Complete Beneficiary Designation Form 102.  Complete Event of Death During Active Membership (Form 104), if applicable.

Section 1: MEMBER INFORMATION First Name

MI

Last Name

Street or P.O. Box

Social Security Number

City

State

Marital Status

Gender

 Single  Married  Divorced  Widowed

 Male  Female

Phone Number

Zip Code

Date of Birth (mm/dd/yyyy)

Email Address

Section 2: EMPLOYMENT INFORMATION /REQUEST RECIPROCITY (see instructions on Page 2) Contribution Information

Benefits Information

I have contributed to CCCERA before this present employment.  Yes**  No

I currently receive a monthly benefit payment from CCCERA.  Yes**  No    

Were you previously employed by Contra Costa County or a District participating in CCCERA? Were you ever a member of any other Public Retirement System in California?

Do you still have retirement funds on deposit with any other Public Retirement System in California?

If your funds are still on deposit with another reciprocal retirement system, do you wish to request reciprocity?

Yes** Yes** Yes** Yes**

   

No No No No

**If your answer is yes to any of the above questions, please provide information on all agencies, dates employed and any other names used. _______________________________________________________________________________________________________________________

   

I certify that I left my funds on deposit (or redeposited my funds) with that employer’s retirement system.

I understand that by accepting employment in a specific retirement system, I am subject to the laws and regulations administered by that system.

I understand that in order to retain the benefits of reciprocity, my contributions may not be withdrawn from CCCERA or any reciprocal public agency retirement system while I am in employment as a member of CCCERA or any reciprocal public agency. Furthermore, this information may be shared with the other retirement system.

Upon signing and returning this document, I am electing to coordinate retirement benefit rights between reciprocal retirement systems, where applicable, and I understand I must retire from all reciprocal systems concurrently.

Section 3: MEMBER ACKNOWLEDGMENT OF INFORMATION Sworn statement – Pursuant to Code 31526 and Code of Civil Procedure Section 2015.5, I declare, under penalty of perjury, that the foregoing statements are full, true, and correct.

Member’s Signature (Required)

Date (mm/dd/yyyy)

Section 4: EMPLOYER CERTIFICATION (To be completed and signed by employer or authorized representative) I certify that the above-named applicant is an employee and that the information is complete and correct to the best of my knowledge, and I have verified the following information.

Full Name of Enrolling Member

Social Security Number

Job Title of Enrolling Member

Date of Birth (mm/dd/yyyy)

Date of Permanent Employment (mm/dd/yyyy)

Employer Name Employer Representative Signature

Working Status (Full Time/Part Time) Employer Representative Name

(PLEASE PRINT)

Contra Costa County Employees’ Retirement Association 1355 Willow Way, Suite 221, Concord, CA 94520 Phone: 925-521-3960  www.cccera.org Page 1 of 2

Scheduled Hours Per Week Date (mm/dd/yyyy)

Election to Coordinate Retirement Benefits between Reciprocal Systems

Form

103 (Rev. 2017)

Reciprocity As a member of CCCERA, you may be eligible for the benefits of reciprocity. Reciprocity is an agreement among public retirement systems to allow members to move from one public employer to another public employer within a specific time limit without losing some valuable privileges related to your retirement benefits.

There is no transfer of funds or service credit between retirement systems when you establish reciprocity. You become a member of both systems and are subject to the membership obligations and rights of each system (for example, minimum retirement age may vary between systems), except as modified by the reciprocity agreement. You must apply to retire from each system separately, and you will receive separate retirement allowances from each system. You must retire on the same date from each public retirement system participating in a reciprocal agreement for all benefits of reciprocity to apply.

Reciprocal Retirement Systems CCCERA is reciprocal with the other county retirement systems under the 1937 Act, as well as CalPERS and any system that has a reciprocal agreement with CalPERS. To verify whether a system has reciprocity with CCCERA, contact our office.

Reciprocity Benefits & Requirements The following benefits and requirements apply to CCCERA members who make a qualified move between reciprocal retirement systems.  Legacy Benefit Tier: The California Public Employees’ Pension Reform Act of 2013 (PEPRA) requires new benefit tiers for new members on or after January 1, 2013. Reciprocal members who were in a legacy (pre-PEPRA) tier with a prior reciprocal employer will be eligible for a legacy tier with CCCERA.  Member Contribution Rate Based on Age at Entry (Legacy Tiers Only): Retirement formulas for CCCERA legacy tier members are based on age at entry; with a lower age at entry generally meaning a lower contribution rate. CCCERA uses the age at entry of the first reciprocal system to determine the contribution rate.  Highest Final Compensation: CCCERA will compute your average final compensation based on the highest rate of pay under any system, as long as you retire on the same date from all systems. Systems will use either a 12- or 36-month consecutive highest final compensation depending on benefit tier.  Qualification for Benefits: Service earned under all reciprocal systems may be used to meet each system’s vesting and retirement eligibility requirements.

Reciprocity Requirements When changing retirement systems, you must satisfy several statutory conditions, as follows, in order to receive the full benefits of reciprocity:  Maintain Membership: You must continue membership in the first retirement system by leaving your service credit and contributions (if any) on deposit.  Movement to a New Reciprocal System: You must have a date of membership in the new system within six months of leaving the old system. When entering CCCERA the six months is extended to one year if termination was due to lay off because of a lack of work, a lack of funds, or a reduction in workforce.  No Overlapping Service: You must discontinue your employment relationship from the first system before entering membership with the subsequent system.  Concurrent Retirement between Reciprocal Systems: In order to receive full reciprocal benefits, you must retire on the same date from both or all systems by submitting a retirement application in accordance to the rules and regulations associated with each system.  Exceptions and Restrictions: Certain exceptions and restrictions may exist. Eligibility for reciprocity is determined by the retirement laws in effect at the time of movement between retirement systems.

Important Restrictions  Concurrent Employment: Reciprocity does not apply when your employment under the first retirement system overlaps your employment under the new system. For the benefits of reciprocity to apply, you must terminate employment under the first system prior to becoming a member of the new system. Reciprocity may not be established even if the overlapping time is due only to using vacation or leave time with the first employer while becoming member of the new system.  Refund Restriction: Some retirement systems may not allow you to withdraw your member contributions while you are employed in a position covered by a reciprocal retirement system.

Reinstatement From Retirement If in the future you reinstate to active employment in a CCCERA-covered position and have retired under reciprocity, there is no provision in the law to allow you to apply reciprocal rights to your subsequent retirement since you will no longer be retired from both systems on the same date.

If you have any questions regarding reciprocity, including the requirements, restrictions or benefits of reciprocity, contact our office.

Contra Costa County Employees’ Retirement Association 1355 Willow Way, Suite 221, Concord, CA 94520 Phone: 925-521-3960  www.cccera.org Page 2 of 2

Form Beneficiary Designation

102 (Rev. 2017)

Section 1: MEMBER INFORMATION

New

First Name

MI

Street or P.O. Box

City

Phone Number

Change

Active

Please check one:

Last Name State

Email Address

Zip Code

Marital Status

Single

Deferred

Social Security Number

Gender

Married

Divorced

Widowed

Male

Female

NOTE: If you are not naming your spouse/registered domestic partner as 100% assigned primary beneficiary, your spouse/partner’s signature is required on the reverse side of this form in Section 4 and must be witnessed by a notary public.

Each person you name that shares the benefit must have a percent assigned and add up to 100%. If you do not indicate a percentage, the benefit(s) will be divided into equal parts. If you need to list additional beneficiaries, follow the same format of this form on a separate sheet of paper, sign/date and attach it. If you are married, in a domestic partnership or have minor children, your spouse/partner or minor children may have superior rights over any other person you name as a beneficiary. Some beneficiaries may not be eligible to receive certain monthly continuances or benefits.

IF YOU ARE NAMING A MINOR: Funds may not be dispersed for minor children until legal guardianship is established. If a beneficiary is a minor and you wish to name an adult to receive and manage payments for the minor without court appointment or court supervision until an age you choose, name the minor as beneficiary using this format: [Name of adult] as custodian for [Name of minor] until age [choose a number at least 18 but not more than 25]. Provide their date of birth, social security number, relationship and use the adult’s address and telephone number.

Alternatively, you may simply name the minor as beneficiary without naming a custodian, in which case court appointment and supervision of a guardian will be required and all funds with be distributed to the beneficiary at age 18.

Unless you provide otherwise, if you name multiple beneficiaries, in the event beneficiaries have pre-deceased you, CCCERA will pay equal shares to the surviving beneficiaries.

In accordance with the County Employees’ Retirement Act of 1937 (CERL), I understand that I am revoking all previously named beneficiaries and now nominate as my beneficiary, to receive any benefits in the event of my death prior to retirement, the following person(s):

Section 2: PRIMARY BENEFICIARY INFORMATION (1) First Name

MI

Last Name

Benefit %

0% Street or P.O. Box Phone Number (2) First Name

City Date of Birth (mm/dd/yyyy) MI

State Social Security Number

.0%

Zip Code Relationship

Last Name

Benefit %

0% Street or P.O. Box Phone Number (3) First Name

City Date of Birth (mm/dd/yyyy) MI

State Social Security Number

.0%

Zip Code Relationship

Last Name

Benefit %

0% Street or P.O. Box Phone Number

City Date of Birth (mm/dd/yyyy)

State Social Security Number

.0%

Zip Code Relationship

Beneficiary information WILL NOT be accepted without your signature. If you are married or in a registered partnership, your spouse/partner’s signature is required in (Section 4) as notification of your change of beneficiary designation. This new designation cancels all previous designations.

Member’s Signature (Required)

Printed Name

Date (mm/dd/yyyy)

TURN OVER

Contra Costa County Employees’ Retirement Association 1355 Willow Way, Suite 221, Concord, CA 94520 925-521-3960 • 925-521-3969 Fax • www.cccera.org

Page 1 of 2

Section 3: SECONDARY BENEFICIARY INFORMATION (1) First Name

MI

Street or P.O. Box

City

Last Name

Benefit %

.0% Phone Number

Date of Birth (mm/dd/yyyy)

(2) First Name

MI

Street or P.O. Box

City

State

Zip Code

Social Security Number

Relationship

Last Name

Benefit %

.0% Phone Number

Date of Birth (mm/dd/yyyy)

Section 4: TRUST INFORMATION

State Social Security Number

Zip Code Relationship

Complete this section only if you are naming a Trust as your beneficiary.

Official Name of Trust

Tax ID Number

Contact Person for Trust

Telephone Number of Contact

Please note that only a lump sum death benefit can be paid to a trust. If your survivor or beneficiary is eligible for a monthly continuance upon your death that continuance cannot be paid to a trust.

Member’s Signature (required only if you are naming a trust)

Date (mm/dd/yyyy)

Section 5: SIGNATURE OF MEMBER’S SPOUSE/PARTNER (Spousal Waiver) Only if 100% is not assigned to your spouse/registered domestic partner trust as your beneficiary.

I acknowledge and consent to this beneficiary designation. I further understand that if a beneficiary, other than myself has been named in Section 2 that I am waiving any survivor benefits to which I may become eligible to receive from CCCERA. Name of Spouse/Registered Domestic Partner (please print)_________________________________________________________ Spouse/Registered Domestic Partner Signature: ____________________________________________ Date: _________________ Must be witnessed by a Notary Public (See Notary Form Below) NOTARY FORM A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California County of _________________________) On ________________ before me, ________________________________________________, (insert name and title of the officer) personally appeared _____________________________________(spouse), who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Notary’s Signature (Required)

Date (mm/dd/yyyy)

Notary Seal

Beneficiary information WILL NOT be accepted without your signature. If you are married or in a registered partnership, your spouse/partner’s signature is required in (Section 4) as notification of your change of beneficiary designation. This new designation cancels all previous designations.

Member’s Signature (Required)

Printed Name

Social Security Number

Contra Costa County Employees’ Retirement Association 1355 Willow Way, Suite 221, Concord, CA 94520 925-521-3960 • 925-521-3969 Fax • www.cccera.org

Date (mm/dd/yyyy)

Page 2 of 2

Death During Active MembershipMember Election Form for Optional Allowance in the Event of Death During Active Membership

Form

104 (Rev. 2017)

Purpose of the form: This form authorizes CCCERA to file an application for non-service connected disability on your behalf, in the event that you are permanently incapacitated by reason of injury or other disability leading to death while you are an active member of CCCERA. This form allows you to preselect an Optional Settlement, pursuant to CERL Section 31762 or 31764 or the successor section.

NOTE: The original document must be submitted. Fax/copies are not accepted.

Section 1: MEMBER INFORMATION Full Name

STOP

Employee #

Social Security #

STOP – Your choice must match the beneficiaries chosen in your Beneficiary Designation Form (Form 102) and a SIGNATURE(s) and adult witness is required below in order for this form to be valid.

Section 2: ELECTION OF OPTIONAL SETTLEMENT

To the Board of Retirement: I choose Optional Settlement 2 (up to 100% continuance to one beneficiary) I only have 1 primary beneficiary listed on Form 102 – Beneficiary Designation Form.

I choose Optional Settlement 4 (up to 100% continuance divided among more than one beneficiary) I have 2 or more primary beneficiaries listed on Form 102 – Beneficiary Designation Form.

Section 3: AUTHORIZATION TO FILE NON-SERVICE CONNECTED DISABILITY RETIREMENT APPLICATION

I understand that the beneficiary(ies) of the allowance that continues after my death is (are) the beneficiary(ies), having an insurable interest in my life, on file at CCCERA at the time of my death as were designated by me on a Beneficiary Designation Form (Form 102), a separate form.

I understand that by signing this form I elect a monthly allowance for my beneficiary(ies) in lieu of any other death benefit including the return of accumulated contributions under CERL Section 31781.

I understand that this election is binding on me unless I withdraw this election before the first payment of any retirement allowance is made to me, and that at retirement I may make another election of an Optional Settlement, or choose to receive the unmodified allowance, under CERL. In accordance with the provisions of CERL, I hereby authorize CCCERA to file an application for a non-service connected disability retirement on my behalf in the event that I am permanently incapacitated by reason of injury or other disability leading to death while I am an active member of CCCERA. I understand that, if granted, this will entitle my survivor(s) to receive a non-service connected disability retirement survivor continuance under Optional Settlement 2 or 4.

In accordance with the provisions of the County Employees Retirement Law of 1937 (CERL), and the by-laws and regulations governing the Contra Costa County Employees’ Retirement Association (CCCERA), I hereby elect an Optional Settlement, pursuant to CERL Section 31762 or 31764 or successor section.

Member Signature (Required)

Date (mm/dd/yyyy)

Adult Witness Signature (Required)

Date (mm/dd/yyyy)

Adult Witness Name (Print)

Contra Costa County Employees’ Retirement Association 1355 Willow Way, Suite 221, Concord, CA 94520 925-521-3960 • 925-521-3969 Fax • www.cccera.org Page 1 of 2

Death During Active MembershipMember Election Form for Optional Settlement Allowance in the Event of Death During Active Membership

Form

104 (Rev. 2017)

Survivor Benefits: Active Member Death (Pre-Retirement) Death and continuing benefits depend on several factors. If a member dies prior to retirement, death benefits are determined based on: Member status (active or deferred) Category of death (service-connected or non-service connected) Retirement Service Credit Relationship of recipient to member (eligible survivor or named beneficiary) To qualify as an eligible survivor in cases involving the death of an active member, a spouse or domestic partner must have been married to or in a duly registered California domestic partnership with the member prior to the member’s death.

No minimum length of marriage or domestic partnership requirement applies.

Type of Death Service-Connected

Basic Death Benefit

Optional Death Allowance

Lump-sum payment of member’s accumulated contributions

Full amount (100%) of disability retirement allowance deceased member would have received had he or she been retired on an Serviceconnected Disability at the time of death

Salary Death Benefit: one month of member’s compensation earnable for each full year of Service Credit (not to exceed six months of compensation) Non-Service Connected Lump-sum payment of member’s accumulated contributions Salary Death Benefit: one month of member’s compensation earnable for each full year of Service Credit (not to exceed six months of compensation)

60% of disability retirement allowance deceased member would have received had he or she been retired on an Non-service Connected Disability* at the time of death

Deferred Member Lump-sum payment of member’s accumulated contributions *In order for the survivor to be eligible for the Optional Death Allowance following a non-service connected death, the member must have been eligible for a retirement in the event of a non-service connected disability.

NON-SERVICE CONNECTED DISABILITY A non-service connected disability means a member’s permanent illness or injury did not arise from his or her employment. Members who have five or more years of retirement service credit and qualify for a non-service connected disability retirement will receive the service retirement allowance to which the member is entitled, or one-third of your annual Final Average Salary, whichever is greater.

In the event of a non-service connected disability event, members who have less than five years of service may take a refund of their contributions and accrued interest, or keep the funds in their account until they are eligible for a deferred retirement allowance (age 70), but they cannot receive a monthly disability allowance.

Contra Costa County Employees’ Retirement Association 1355 Willow Way, Suite 221, Concord, CA 94520 925-521-3960 • 925-521-3969 Fax • www.cccera.org Page 2 of 2

\

EMERGENCY CONTACT FORM Name:

District Employee Number:

Street Address:

P.O. Box (if any):

City:

Zip Code:

Home Phone Number:

Cell Phone Number:

NAME OF PERSON TO NOTIFY IN EMERGENCY Name:

Relationship:

Address:

City:

Home Phone:

Cell Phone:

State:

Business Phone: ALTERNATE EMERGENCY CONTACT Name:

Relationship:

Address:

City:

Home Phone:

Cell Phone: Business Phone: DEPENDENT INFORMATION (if applicable)

Spouse:

Date of birth:

Dependent child:

Date of birth:

Dependent child:

Date of birth:

Dependent child:

Date of birth:

Dependent child:

Date of birth:

Dependent child:

Date of birth:

______________________________________ Date (Updated 8/1/13)

State:

EMPLOYEE EQUAL EMPLOYMENT OPPORTUNITY DATA FORM For purposes of compliance with the Equal Employment Opportunity Commission State and Local Government Information (EEO-4) Report, please indicate the category which is applicable to you: A. WHITE (not of Hispanic origin): All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

B. BLACK (not of Hispanic origin): All persons having origins in any of the Black racial groups of Africa.

C. HISPANIC: All persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

D. ASIAN OR PACIFIC ISLANDER: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa.

E. AMERICAN INDIAN OR ALASKAN NATIVE: All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

Employee Signature

Employee Name â&#x20AC;&#x201C; Please Print

Employee #

Date

(EEO-4 09/01/93)

CONFIDENTIALITY ACKNOWLEDGEMENT As a Firefighter / Paramedic for the San Ramon Valley Fire Protection District, I understand that I will, on occasion, be exposed to confidential information in the course of my duties.

Confidential information includes, but is not limited to, the Districtâ&#x20AC;&#x2122;s administration of employer-employee relations, community projects, patient care, and various other types of sensitive information.

I understand the confidentiality requirements of my position require that I abide by all expectations of privacy and confidentiality the District has of me regarding any and all information. I agree to do so. I also understand that any breach of confidentiality on my part may lead to disciplinary action, up to and including termination of employment with the San Ramon Valley Fire Protection District.

Signature:

Print Name:

Date:

OFF – DUTY DISTRICT EXERCISE FACILITY USE/RECREATIONAL ACTIVITY AGREEMENT

The San Ramon Valley Fire Protection District exercise facilities are made available for the personal use of District employees. The use of these facilities is not a condition of employment. Any injuries occurring as a result of off-duty use of these facilities, as well as injuries which might occur as a result of engagement in recreational, social, or athletic activities while off-duty, are not covered under Worker’s Compensation laws pursuant to Labor Code 3600(a)(9).

By my signature below, I agree and understand that I am not covered by Worker’s Compensation Laws pursuant to Labor Code 3600(a)(9) while using District exercise facilities and/or while engaged in recreational, social, or athletic activities during off-duty time.

Signature

Print Name

Date

San Ramon Valley Fire Protection District Cellular Telephone Use Agreement Effective: ______________

Option 1: No Personal Use I choose to not use my District cell phone for personal use. I understand that infrequent average use of less than 60 minutes per month is acceptable. No personal text messaging is allowed under this option. I understand that I am required to review my cell phone bill each month and identify personal phone calls and personal text messages. I understand that if personal usage exceeds restrictions, I will be required to meet with my manager to determine cellular phone alternatives. I understand that I am responsible to reimburse the District for personal usage that exceeds restrictions according to the rate plan currently in effect. I understand that I am financially responsible for any and all cellular telephone usage that is not in conformance with Policy. I understand that my cellular activity may be subject to the Public Records Act.

Option 2: Reimburse District for Personal Use I choose to use my District cell phone for personal calls. I agree to pay $35 per month, through payroll deduction, for this privilege. I understand that I am financially responsible for any and all cellular telephone usage that is not in conformance with Policy. I understand that my cellular activity may be subject to the Public Records Act.

I also understand that California law generally prohibits the use of hand-held cell phones while driving a motor vehicle. I agree to abide by the restrictions included in the California vehicle code.

______________________________________ Signature

_____________________________________ Printed Name

________________________________ Date

MEDICAL INSURANCE COVERAGE WAIVER FORM Please read and initial all: ___

I am currently covered by an alternate medical insurance plan. I would like to waive my District medical insurance benefit and receive $300 per month in lieu of the District medical insurance benefit.

___

I have attached proof of my alternate medical insurance coverage.

___

I understand that if I lose my alternate medical insurance coverage, I must notify the District Administrative Services Department within 15 business days.

___

I understand that if I lose my alternate medical insurance coverage, I am no longer eligible to receive the $300 per month benefit; and that if I receive the $300 per month benefit during any month that I do not have alternate medical insurance coverage I will be held responsible for reimbursing the District for the amount of benefit I received during that time. I understand and agree that reimbursement would be via payroll deduction.

___

I understand that if I lose my alternate medical insurance coverage, mid-year, I may qualify to reenroll into the District’s medical insurance plan. I further understand that re-enrolling outside the annual Open Enrollment period must be approved by PERS as a “qualifying event”.

___

I understand that if I choose to re-enroll into the District’s medical insurance plan, I can do so during any annual Open Enrollment period – effective the following January 1.

___

I understand that if I retire from the District while participating in the medical insurance waiver option, I can enroll back into the District’s retiree medical insurance coverage so long as I retired from the District within 120 days of my last day of work with the District; and that after retirement I can re-enroll into the District’s medical insurance plan during any future, annual Open Enrollment period or if I should experience a qualifying event (i.e., loss of other coverage).

Employee Name (print): ___________________________________________

Date: _____________

Employee Signature: _________________________________________________________________ HR Approval: ___________________________________________________

Date: _____________

Finance Approval: _______________________________________________

Date: _____________

Effective date: ___01/01/2017__________________ First Date of Reimbursement: _______________

SAN RAMON VALLEY FIRE PROTECTION DISTRICT DECLINE of Non-Medical Benefits Election Form

Name: Hire Date: Badge #:

____________________ ____________________ ____________________

WAIVER: If you do not wish to participate in any/all District-sponsored non-medical health benefits, please indicate by checking the box(es) below: I do not wish to participate in the following benefit insurance plans: Dental  Vision  Life/AD&D  Employee Assistance Plan 

____________________________________________ Signature ________________________ Date

MEDICAL PREMIUM RATES (Monthly): (Rates effective 1/1/17 - 12/31/17)

2017 RATES BAY AREA Blue Shield Access + Blue Shield NetValue Kaiser United Healthcare HMO

SINGLE COVERAGE 2-PARTY COVERAGE 3-PARTY COVERAGE Plan Employee District Plan Employee District Plan Employee District Premium Contribution Contribution Premium Contribution Contribution Premium Contribution Contribution $1,024.85

$81.99

$942.86

$2,049.70

$163.98

$1,885.72

$2,664.61

$213.17

$2,451.44

$1,349.44

$1,906.81

$152.54

$1,754.27

(Cap - 2017)

NO longer offered in 2017 $733.39

$58.67

$1,062.26 81.99+37.41

$674.72

$1,466.78

$117.34

$942.86

$2,124.52 163.98+74.82

$1,885.72

$2,761.88 213.17+97.27

$2,451.44

HealthNet SmartCare

$733.29

$58.66

$674.63

$1,466.58

$117.33

$1,349.25

$1,906.55

$152.52

$1,754.03

Anthem Blue Cross - HMO Select Anthem Blue Cross - HMO Traditional

$783.46 $990.05

$62.68 $79.20

$720.78 $910.85

$1,566.92 $1,980.10

$125.35 $158.41

$1,441.57 $1,821.69

$2,037.00 $2,574.13

$162.96 $205.93

$1,874.04 $2,368.20

Blue Cross - PERS Choice Blue Cross - PERS Select Blue Cross - PERS Care

$830.30 $736.27 $932.39

$66.42 $58.90 $74.59

$763.88 $677.37 $857.80

$1,660.60 $1,472.54 $1,864.78

$132.85 $117.80 $149.18

$1,527.75 $1,354.74 $1,715.60

$2,158.78 $1,914.30 $2,424.21

$172.70 $153.14 $193.94

$1,986.08 $1,761.16 $2,230.27

(Cap - 2017) (Above Cap - 2017)

(Above Cap - 2017)

Please attach copies of: - Child's birth certificate - Marriage / Domestic Partner certificate California Public Employees' Retirement System P.O. Box 942715 Sacramento, CA 94229-2715 HEALTH BENEFIT PLAN ENROLLMENT FORM DO NOT SEND MEDICAL PERS-HBD-12 (Rev. /1 ) CLAIMS TO THIS ADDRESS PLEASE TYPE 2. SOCIAL SECURITY NUMBER

1. TYPE OF ACTION

A C T I O N

(Check One) a. NEW enrollment b. CHANGE of coverage

C O D E

3. SPOUSE/DOMESTIC PARTNER'S SOCIAL SECURITY NUMBER

(FIRST)

4A.

Mo. Day Yr. (MI)

(LAST)

(MI)

(LAST)

(MI)

(LAST)

(MI)

(LAST)

G E N D E R

Family Relationship M

C O D F E

SELF

SSN

Name (FIRST)

(MI)

(LAST) (LAST)

Daytime Phone

City, State, ZIP

4B. RESIDENCE ZIP CODE 5.

DATE OF BIRTH

LIST ALL PERSONS (including self) TO BE ENROLLED IN: 17. BASIC PLAN

c. CANCEL all coverage

Mailing Address

CalPERS USE ONLY - DOCUMENT REFERENCE NUMBER

Please check if Permanent Intermittent Employee (applies to active State employees only)

(FIRST)

Evening Phone

SSN (FIRST)

(If different from 4A)

6. GENDER Male Female

7. MARRIED Yes No

SSN (FIRST)

8. PLAN CODE

9. NAME OF HEALTH PLAN

10. GROSS PREMIUM $

11. PRIMARY CARE PHYSICIAN/MEDICAL GROUP

12. PRIOR PLAN CODE

13. PRIOR HEALTH PLAN

SSN

14. Reason Code

15. Permitting Event Date 16. EFFECTIVE DATE Mo.

Day

Yr.

Mo.

Day

01

A C T I O N

C O D E

18. SUPPLEMENTAL PLAN (FIRST)

(MI)

DATE OF BIRTH (LAST)

Mo. Day

Yr.

Relationship

C O D E

Yr.

19. CHECK ONE I DO NOT elect to enroll in a Health Benefits Plan under the Public Employees' Medical and Hospital Care Act. , (/(&7 72 (152// ,1 25 &+$1*( 72 a Health Benefits Plan as shown in Items 8 and 9 above and authorize deductions to be made from my salary or retirement allowance to cover my share of the cost of enrollment as it is now or as it may be in the future. I also certify that the names of all dependents listed above in items 17 and/or 18 are eligible family members as defined in the Public Employees' Medical and Hospital Care Act. , DP YROXQWDULO\ HQUROOLQJ LQWR WKH VHOHFWHG +HDOWK 3ODQ , DJUHH WR UHDG WKH DVVRFLDWHG (YLGHQFH RI &RYHUDJH (2& DQG DQ\ VXEVHTXHQW (2&V LQ WKH IROORZLQJ \HDUV WR XQGHUVWDQG WKH EHQHILWV RI WKH 3ODQ 7KH 6XEVFULEHU DQG DOO HOLJLEOH GHSHQGHQWV DJUHH WR DOO WKH WHUPV DQG FRQGLWLRQV RI WKH (2& DQG WKH +HDOWK 3ODQ , (/(&7 72 &$1&(/ the Health Benefits Plan as shown in items 12 and 13 above.

20. EMPLOYEE OR ANNUITANT'S SIGNATURE (see privacy information on reverse of employee copy)

21. DATE SIGNED Mo.

Day

TELEPHONE NUMBER ( )

PLEASE REFER TO THE HEALTH BENEFITS PROCEDURE MANUAL FOR COMPLETION OF ITEMS 22-27

22. DEDUCTION PLAN CODE

23.Type of 1. action 2.

(Check One) 3.

New Cancel Change

24. PAY PERIOD 25. PARTY CODE Month Year 29. PAYROLL OFFICE CODE

28. AGENCY NAME (or Retirement System) 32. I hereby certify under penalty of perjury as follows: That I am a duly appointed, qualified and acting officer of the above named agency, and that payment by the agency as provided by Sections 22870-22905 of the Government Code is hereby approved. Final determination of eligibility for the enrollment action specified will be made by the Board of Administration, Public Employees' Retirement System, in accordance with the Public Employees' Medical and Hospital Care Act.

SIGNATURE OF HEALTH BENEFITS OFFICER

35. REMARKS ___________ of__________ Forms WHITE â&#x20AC;&#x201C; HB PINK â&#x20AC;&#x201C; Agency BLUE - Employee

26. EMPLOYEE DESIGNATION

27. BARGAINING UNIT

30. AGENCY CODE

31. UNIT CODE

33. Date received in employing office Mo.

Day Day

Year

34. PHONE NUMBER

Year

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No enrollment form needed

Your Vision Benefits Summary Get the best in eye care and eyewear with SAN RAMON VALLEY FIRE PROTECTION DISTRICT and VSP® Vision Care.

Using your VSP benefit is easy.

Create an account at vsp.com. Once your plan is effective, review your benefit information.

Find an eye care provider who’s right for you. The decision is yours to make—choose a VSP provider or any out-of-network provider. To find a VSP provider, visit vsp.com or call 800.877.7195.

Benefit

Description Your Coverage with a VSP Provider Focuses on your eyes and overall wellness Every 12 months

WellVision Exam

Frame

$130 allowance for a wide selection of frames $150 allowance for featured frame brands 20% savings on the amount over your allowance Every 12 months

Combined with exam

Lenses

Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Every 12 months

Combined with exam

Lens Enhancements

Tints/Photochromic adaptive lenses Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 35-40% on other lens enhancements Every 12 months

Contacts (instead of glasses)

$130 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation) Every 12 months

Best Eye Care You’ll get the highest level of care, including a WellVision Exam®– the most comprehensive exam designed to detect eye and health conditions. Plus, when you see a VSP provider, you'll get the most out of your benefit, have lower out-of-pocket costs, and your satisfaction is guaranteed.

Choice in Eyewear From classic styles to the latest designer frames, you’ll find hundreds of options. Choose from featured frame brands like bebe®, Calvin Klein, Cole Haan, Flexon®, Lacoste, Nike, Nine 1 West, and more . Visit vsp.com to find a Premier Program location that carries these brands. Prefer to shop online? Check out all of the brands at Eyeconic.com, VSP's online eyewear store.

$0 $50 $80 - $90 $120 - $160

Up to $60

Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.

30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam.

Plan Information VSP Coverage Effective Date: 01/01/2017 VSP Provider Network: VSP Signature

$10 for exam and glasses

Prescription Glasses

At your appointment, tell them you have VSP. There’s no ID card necessary. If you’d like a card as a reference, you can print one on vsp.com.

That’s it! We’ll handle the rest—there are no claim forms to complete when you see a VSP provider.

Copay

Extra Savings

Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor Your Coverage with Out-of-Network Providers

Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.

Visit vsp.com or call 800.877.7195 for more details on your vision coverage and exclusive savings and promotions for VSP members.

1

Brands/Promotion subject to change.

©

2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.

Exam .................................................. up to $50 Frame ................................................ up to $70 Single Vision Lenses ............... up to $50 Lined Bifocal Lenses ............... up to $75

Lined Trifocal Lenses ............ up to $100 Progressive Lenses .................. up to $75 Contacts ........................................ up to $105 Tints ....................................................... up to $5

VSP guarantees coverage from VSP network providers only. Coverage information is subject to change.

In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.

No enrollment form needed.

SRVFPD Self Funded Vision Plan Options Secondary Vision Plan Coverage SAN RAMON VALLEY FIRE PROTECTION DISTRICT (Hereinafter Called Group) AGREE AS FOLLOWS: The Group shall provide supplemental second pair of glasses and covered contact lenses subject to the terms and conditions of this document: I.

TERM AND CANCELLATION

These benefit options shall coincide with the VSP document duration.

Final July 7, 2008

1

II.

ELIGIBILITY DETERMINATION

Eligibility for these benefits is subject to the individual’s enrollment in the underlying VSP Plan C. No coverage is available for the supplemental benefits if an individual is not also enrolled under VSP Plan C. EMPLOYEES For purposes of this Plan, eligible participants shall be defined as all full-time employees of the employer who work forty (40) or more hours per week at the employer’s normal place of business. Aso, covering retirees who wish to participate.

New employees shall be added on the first day of employment.

Terminating employees shall be excluded from the Plan on the last day of the month in which their employment terminates with the exception of retirees who chose to enroll in the VSP Plan C. DEPENDENTS If dependent coverage is provided under this document, then for the purposes of this Plan, dependents eligible shall be the covered employee’s spouse and unmarried dependent children who have not attained their nineteenth (19th) birthday, or through their twenty-third (23rd) birthday if attending school full-time.

An unmarried child age nineteen (19) or over may continue to be eligible as a dependent if the child is: 1. Incapable of self-sustaining employment by reason of mental or physical handicap 2. Chiefly dependent upon the covered employee or retiree for support and maintenance.

PROVIDED, HOWEVER, proof of such incapacity and dependency is furnished to the Group by the Covered Person within thirty-one (31) days of the request for such information by the group. Additional information may be subsequently required by the Group but not more frequently than annually after the two-year period following the child’s attainment of the limiting age.

CONTINUATION COVERAGE The Consolidated omnibus Budget reconciliation Act of 1985 (COBRA) requires that under certain circumstances health plan benefits available to an eligible participant and his or her dependents be made available for purchase by said persons upon the termination of employment of said participant, or the termination of the relationship between said participant and his or her dependents. If, and only to the extent, COBRA applies to the parties to this document, the Group shall make the statutorily required continuation coverage available for purchase in accordance with COBRA.

Final July 7, 2008

2

A. ADDITIONAL BENEFIT – SECOND PAIR OF GLASSES AND CONTACT LENSES 1. The availability of coverage under this benefit is such that a covered person may purchase either a second pair of glasses or contact lenses up to the allowable limits described herein, not both, under the self funded portion of the plan.

2. The above mentioned benefits will be covered as follows:

Deductible: Maximum Benefit: Frames Only Lenses Only

Second Pair of Glasses

Additional Covered Contact Lenses

$20

$25

$90 every 12 months $160 every 12 months

N/A $250

The Group will pay up to $160 for any necessary prescription lenses including single vision, bifocal, trifocal, or other more complex lenses necessary for the patient’s visual welfare.

The Group will not provide any benefit for professional service or materials connected with the following: • • • • • •

WellVision Exam Orthoptics or vision training and any associated supplemental testing Plano lenses Two pairs of glasses in lieu of bifocal Medical or surgical treatment of the eyes Any eye examination, or corrective eyewear, required by an employer as a condition of employment.

Lenses and frames furnished under this program which are lost or broken will not be replaced except at the normal intervals when services are otherwise available.

3. The benefit period shall coincide with the VSP plan year.

4. The availability of coverage is subject to the purchase of frames, lenses, or contact lenses under VSP Plan C. Available coverage under the VSP Plan C must be utilized prior to submitting reimbursement requests under the San Ramon Valley Fire Protection District Self Funded Vision Plan.

NOTE: The San Ramon Valley Fire Protection District Self Funded Vision Plan does not cover any cost differences between eyewear or contacts selected by the employee/retiree or eligible dependents and the available coverage under the VSP Plan C.

Final July 7, 2008

3

III. GENERAL PROVISIONS

1.

The Group acts as a contracting agency hereunder to enable the Covered Persons to acquire supplemental vision benefit options. Under no circumstances shall the Group be liable for the negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or organization performing services or supplying materials in connection with this document.

2.

If any provision of this document is declared invalid or unenforceable, the remaining provisions hereof shall remain in full force and effect.

3.

Neither this document, nor any benefits hereunder, including the payment of money, is assignable, except with the prior consent of the Group.

4.

The Group reserves the right to reject any and all claims for services or benefits which are filed more than one hundred eighty (180) days after completion of services.

5.

It is the responsibility of the Group representatives to disseminate notice with respect to material matters to Covered Persons in the Group.

6.

The funding policy for the Group Plan shall be self funded by the group on behalf of the employee or retiree, subject to the limitations described herein.

7.

The named Plan Administrator for this Plan shall be designated as the SAN RAMON VALLEY FIRE PROTECTION DISTRICT SELF FUNDED VISION PLAN and shall have authority to control and manage the operation and administration of the Plan on behalf of the employees or retirees.

Final July 7, 2008

4

IV. CLAIMS APPEAL PROCEDURES COMPLAINTS â&#x20AC;&#x201C; BENEFIT ELIGIBILITY 1. If a claim for benefits is denied, the Group will notify the claimant in writing of the specific reasons for the denial, including specific references to pertinent Plan provisions.

The Group will also describe any additional materials or information necessary.

2. If the claimant, or the duly authorized representative, so requests within ninety (90) days of the date of receipt of written denial of the claim, the Group or its designated Plan Administrator will review the decision denying the claim.

3. The Group or its designated Plan Administrator will give the claimant a reasonable opportunity for a full and fair review of the decision denying the claim. The claimant will be given the opportunity to review pertinent documents, and to submit any statements, documents, or written arguments in support of this claim.

4. If thereafter claim is denied, the Group or its designated Plan Administrator will, within sixty (60) days after receipt of the request for review, advise the claimant in writing of the specific reasons for the decision, including specific references to the pertinent Plan provisions on which a decision is based.

IF GROUP OR COVERED PERSONS HAVE ANY QUESTIONS ABOUT BENEFITS OR PROFESSIONAL SERVICES RECEIVED, CONTACT THE GROUP.

Final July 7, 2008

5

ADDENDUM ADDITIONAL BENEFIT COVERED CONTACT LENSES

I.

BENEFITS

Persons covered under this additional benefit are entitled to contact lenses which are referred to by the GR0UP as “covered” as opposed to those which are defined as “necessary” under the standard group coverage.

A. Covered Persons may receive contact lenses if in the opinion of the Member Doctor the patient can successfully wear contact lenses.

B. For each Covered Person seeking services under this benefit, there shall be a deductible as follows: TYPE OF LENS FITTING Hard Contact Lenses Soft Contact Lenses Multifocal Contact Lenses or Extended Wear (Firm or Soft)

AMOUNT OF DEDUCTIBLE $25.00 $25.00 $25.00

Because of the unique nature of fitting contact lenses, experience has shown that there must be substantial patient motivation. There is also significant time involved on the doctor’s part whether or not the procedure is successful. For these reasons, the deductible is not refundable to the covered person in any case.

C. There is an annual limitation of $250 for the additional benefit of covered contact lenses.

II.

EXCLUSIONS

The following items are not covered under the contact lense benefit of this plan: A. B. C. D. E.

Orthokeratology Replacement of lost or damaged lenses Modifications of lenses Routine maintenance such as polishing Refitting (change in lens design) after the initial fitting This will be the responsibility of the Covered Person.

REIMBURSEMENT BENEFITS ARE NOT ASSIGNABLE.

Final July 7, 2008

6

SRVFPD Intranet 457 Deferred Compensation Plans CalPERS CalPERS 457 Forms, and select Plan Forms Group #: 450655 Third-Party Administrator is Voya Contact: Tamika Workmon (at Voya) - (888) 713-8244, option 2 Email: tamika.workmon@voya.com Website: https://calpers.voyaplans.com CalPERS 457 Customer Service - (800) 260-0659 ICMA ICMA-RC 457 Forms Group #: 304588 Contact: Chad Parilla - (866) 749-5177 Investor Services - (800) 669-7400 Email: cparilla@icmarc.org Website: www.icma-rc.org Nationwide Nationwide 457 Forms or Participant Change Form Internal Plan ID: 0036509001 Group #: 0585 Contact: Jake Sours - (916) 708-1320 Email: soursj1@nationwide.com Website: www.nrsforu.com

California Association of Professional Firefighters A Non-Profit Mutual Benefit Association Post Office Box 31, Martell, CA 95654-0037 (209) 223-3971. . (800) 832-7333 . Fax (209) 223-2966

www.capf.org

CAPF $19.50 Plan Safety & Non-Safety Benefit Illustration FeaturesÆenefits

Safety Members

Non-Safety Members

Monthly Cost

$19.50 per month, level cost payroll deduction

$19.50 per month, level cost payroll deduction

Percentage Of Wages

1007o of wages for Catætrophic Disabilities for up to 30 months 807o of wages Non-Industrial Disability 70o/o of wages Industrial Disabilþ (75% with deductible income) (No Workers' Compensation Permanent Disability offsets) Maximum Benefit of $10,000 per month, lax-free

807o of wages for Catætrophic Disabilities for up to l8 months 662l3Yo of wages Non-lndustrial Disability 662l3%o of wages Industrial Disability (No Workers' Compensation Permanent Disability offsets) Maximum Benefit of $10,000 per month, tax-free

30 Calendar days - Earlier reduced benefrts may be payable based on lack ofpersonal leave down to zero days. $750 per month Minimum Benefit after 60 days ($500 per month Industrial caused), freeze ofpersonal leave after 60 days. No benefits a¡e payable if working full-time, light or modified duty

30 Calendar days - Earlier reduced benefits may be payable bæed on lack ofpersonal leave down to zero days. $750 per month Minimum Benefit after 60 days ($500 per month if Industrial caused), freeze ofpersonal leave after 60 days. No benefits are payable if working full-time, light or modified duty

Benelit Period

Lifetime: Sickness, Accident and Pregrancy

Three Years (36 months): Sickness, Accident and Pregnancy

Sick Leave Integration Benefit

After 60 days, you may use 50oá personal leave and receive 507o benefit from the Plan or use I 00% personal leave and receive $750 per month ($500 per month iflndustrial caused)

After 60 days, you may use 50% personal leave and receive 500á benefit from the Plan or use l00o/o personal leave and receive $750 per month ($500 per month iflndustrial caused)

4%o compounded per year (years 2-7) thereafter,

47o compounded per year (years 2-3)

Protected*

Waiting Period

if

Cost of Living Benefit (COLA)

age 65 and then continued

CPI increase to

lifetime benefits Covered, no restrictions lifetime lndustrial and NonJndustrial

Musculoskeletal & Connective

Covered, no restrictions lifetime Industrial and Non-Industrial

Tissue Disorders

causes

causes

Waiver of Payment

Waiver of Payment after no-pay status

'Waiver of Payment after no-pay status

Benefits Payable During

Afrer 60 calendar days

Challenged Workers' Compensation Cases

Minimum Monthly Benefit Death Benefit

+"3'l Pr0c¿ss

- 707o of wages to a Maximum Benefit $10,000 per month (Repayable only ifsettled in your favor) $750 per month - paid in addition to personal leave after 60 calendar days. ($500 pe¡ month iflndustrial caused)

of After 60 calendar

days - 66 2l3yo of wages to a Maximum Benefit of$10,000 per month (Repayable only ifsettled in your favor)

5750 per month - paid in addition to personal leave after 60 calendar days. ($500 per month iflndustrial caused)

$15,000 Death Benefit on- or off-duty natural, accidental or

$15,000 Death Benefit on- or off-duty natural, accidental or

terminal illness

terminal illness

(Benefits may

be

payable within 24 hours of notification)

(Benefits may

be

payable within 24 hours of nolifcation)

Nine (9) months additional benefits to dependent beneficiary

Survivorship Benefit

Nine (9) months additional benefits to dependent beneficiary

Pre-Existing Medical Condition Coverage

If you enroll during your initial enrollment period, all pre-existing Ifyou enroll during your initial enrollment period, all pre-existing

Ownership of PIan

medical conditions will be covered once you have been in the Plan for twenty-four Q4)fforry-eight (48)+* months, unless you are eligible fot the Prior Coverage Credil - otheruise, preexisting medical conditions will not be covered.

medical conditions will be covered once you have been in the Plan for twenty-four (24)/forty-eight (48)** months, unless you are eligible for the Prior Coverage Credit - otherwise, preexisting medical conditions will not be covered.

Owned, operated and managed by its Participa¡ts through a represontative Board of Directors (non-profit California Corporalion since I 985)

Owned, operated and managed by its Participants through a representative Boa¡d of Directors (non-profit California Corporation since I 985)

*

Benefits from Other Sources ue applied to reduce amount payable from the Plan *+ Forty-eight months for HIV, AIDS, ARC md for eligibility of Death Benefits on Pre-existing Conditions,

Association), Itenjoysnon-profitstatsfomtheU.S.DepartrnentoftheTreasurIRSCode501(c)(9),ædisaVolunteerEmployeeBenefitAssociationunderERISAlawsoftheU.S principles.

8-12 ILLUSTRATION ONLY. Certain conditions may apply, see Plan Documents for details. CA Insurance Lic. #0544968

INSURANCE ADMINISTRATORS: California Administration Insurance Serwices, Inc @-r=,::.:

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San Ramon Valley Fire Care Group M Miissssiioonn SSttaatteem meenntt The San Ramon Valley Fire Care Group exists to provide quality support and care to the best of our ability to our fire families.

Established in 1999, the San Ramon Valley Fire Care Group serves all District employees, retirees, volunteers, and their families. Support and assistance may come by way of providing acknowledges exciting events such as the birth of a child, adoption, or other joyous and special occasions.

All outreach and communication is confidential and behind the scenes. The group is managed by individuals who are employees that volunteer their time. These individuals are dedicated to working within the parameters of the bylaws and budget, as well as the mission statement and goals of the group.

The San Ramon Valley Fire Care Group is supported financially by private donations and employee payroll deductions.

Employees can sign up for automatic payroll deduction by

completing a payroll deduction form. Completed forms should be forwarded to the San Ramon Valley Fire Protection District, Finance Division, located at 1500 Bollinger Canyon Road, San Ramon, CA 94583.

The

San

Ramon

Valley

Fire

Care

Groupâ&#x20AC;&#x2122;s

confidential

email

address

is

SRVFCareGroup@gmail.com. Requests or suggestions for assistance can be made through email, or by contacting Natalie Probert, Chairperson, at 925-786-6780 or by contacting any other current members.

In times of need and crisis, help and assistance can come in many forms and ways. Any contribution can make a significant difference in serving our fire families!

San Ramon Valley Fire Care Group 1500 Bollinger Canyon Road San Ramon, CA 94583 Natalie Probert, Chairperson David Atkin, Vice Chairperson

San Ramon Valley Fire Care Group

VOLUNTARY PAYROLL DEDUCTION AUTHORIZATION FORM San Ramon Valley Fire Protection District employees may direct payroll deductions to the San Ramon Valley Fire Care Group. Upon your authorization, a monthly deduction will be made through the Districtâ&#x20AC;&#x2122;s payroll department. Payroll deductions listed below will go directly to the San Ramon Valley Fire Care Group.

The San Ramon Valley Fire Care Group donations are not tax deductible.

Employee Name: Deduction Effective Date:

Emp. #: Monthly Contribution Amount $

I authorize the monthly payroll deduction. This authorization will remain in effect until rescinded in writing by the employee (see Rescission).

Employee Signature:

Date:

RECISSION I hereby rescind the voluntary monthly payroll deduction directed to the San Ramon Valley Fire Care Group in the amount of $ Employee Signature:

effective

.

Date:

San Ramon Valley Fire Care Group 1500 Bollinger Canyon Road San Ramon, CA 94583 Natalie Probert, Chairperson David Atkin, Vice Chairperson

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY 200 Hopmeadow Street Simsbury, Connecticut 06089 (A stock insurance company)

ENROLLMENT FORM EMPLOYER INFORMATION ENROLLMENT INFORMATION

EMPLOYEE INFORMATION

EMPLOYER’S FULL LEGAL NAME San Ramon Valley Fire Protection District Please check one of the following: INITIAL ENROLLMENT CHANGE TO EXISTING ENROLLMENT FAMILY STATUS CHANGE (TYPE): EMPLOYEE NAME

GROUP POLICY# 0GL 377068 or SR8 311732

DATE OF BIRTH

ADDRESS SPECIALTY/OCCUPATION DEPENDENT INFORMATION

APPLICABLE BENEFIT ELECTIONS

EFFECTIVE DATE: EFFECTIVE DATE: EFFECTIVE DATE: EMPLOYEE ID/SSN DATE OF HIRE

CITY EARNINGS (AS DEFINED BY THE POLICY) $ HR MO YR

STATE # HOURS WORKED PER WEEK

SPOUSE’S NAME

GENDER

M

F

DATE OF BIRTH

CHILD’S NAME

GENDER

M

F

DATE OF BIRTH

CHILD’S NAME

GENDER

M

F

DATE OF BIRTH

CHILD’S NAME

GENDER

M

F

DATE OF BIRTH

CHILD’S NAME

GENDER

M

F

DATE OF BIRTH

ZIP CODE LOCATION DATE OF MARRIAGE

Please make your benefit elections by checking the appropriate box. Contact your employer for plan details.

SHORT TERM DISABILITY YES NO COST: SM For DISABILITYFLEX choose: WEEKLY BENEFIT CHOICE BENEFIT DURATION BENEFIT COMMENCEMENT PERIOD $ LONG TERM DISABILITY YES NO COST: BASIC LIFE AND AD&D* EMPLOYEE YES $ 20,000 NO COST: SPOUSE YES $ NO COST: CHILD YES $ NO COST: *If applicable, the accidental death benefit (AD&D) will equal the face amount of the life insurance elected.

SUPPLEMENTAL LIFE AND AD&D* EMPLOYEE YES $ NO COST: SPOUSE YES $ NO COST: CHILD YES $ NO COST: *If applicable, the accidental death benefit (AD&D) will equal the face amount of the life insurance elected.

SUPPLEMENTAL AD&D EMPLOYEE YES $ NO COST: SPOUSE YES $ NO COST: CHILD

YES $

NO

COST:

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies is Simsbury, CT Form PA-9604

Page 1 of 3 Version 4.2013

BENEFICIARY INFORMATION

You must select your beneficiary – the person (or more than one person) or legal entity (or more than one entity) who receives a benefit payment if you die while covered by the plans. Please make sure that you also name a contingent beneficiary – who would receive your benefit if your primary beneficiary dies first.

Please make sure your beneficiary designation is clear so that there will be no question as to your meaning. If you name more than one primary or contingent beneficiary, show the percentage of your benefit to be paid to each beneficiary. Please provide all of the information requested below. If your beneficiary is not related either by blood or by marriage, insert the words, “Not Related” as their stated relationship. If you need assistance, contact your benefits administrator or your own legal advisor.

This beneficiary designation will be for ALL group life or accidental death insurance coverage issued by The Hartford for you. A primary beneficiary is the beneficiary or beneficiaries that you name to receive the benefits if they are living at the time of your death.

The primary beneficiaries are the first in line to receive death benefits. Contingent beneficiaries, or secondary beneficiaries, are those named to receive the insurance proceeds if no primary beneficiary is alive at the time you die.

PRIMARY BENEFICIARY NAME

SOCIAL SECURITY #

DATE OF BIRTH

ADDRESS NAME

RELATIONSHIP

PERCENTAGE

PHONE NUMBER SOCIAL SECURITY #

DATE OF BIRTH

ADDRESS

RELATIONSHIP

PERCENTAGE

PHONE NUMBER

CONTINGENT BENEFICIARY NAME

SOCIAL SECURITY #

DATE OF BIRTH

ADDRESS NAME ADDRESS

RELATIONSHIP

PERCENTAGE

PHONE NUMBER SOCIAL SECURITY #

DATE OF BIRTH

RELATIONSHIP

PERCENTAGE

PHONE NUMBER

The beneficiary for insurance on the lives of your dependents will automatically be you, if surviving. Otherwise, the beneficiary will be subject to policy provisions. A beneficiary for employee life or accidental death insurance may be changed upon written request.

Consent For Community Property States Only: If you live in a community property state – Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin – you may complete the Spousal Consent section, which allows your spouse to waive his or her rights to any community property interest in the benefit. Disclaimer: Spousal consent does not apply to ERISA plans. Certain tribal jurisdictions may also require spousal consent. Please see your Benefits Administrator for details.

This will represent that, as spouse of the employee named above, I hereby consent to my spouse designating the person(s) listed above as beneficiaries of group life or accidental death insurance under the above policy and waive any rights I may have to the proceeds of such insurance under applicable community property laws. I understand that this consent and waiver supersede any prior spousal consent or waiver under this plan.

SPOUSAL CONSENT SIGNATURE

DATE

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies is Simsbury, CT Page 2 of 3 Version 4.2013

CONFIRMATION

I acknowledge that I have been given the opportunity to enroll in the insurance coverage offered by my employer. I understand and agree that if I decline coverage now, but later decide to enroll, I may be required to provide evidence of insurability that is satisfactory to The Hartford and be approved for such coverage before it becomes effective. I understand my request for coverage may be denied

by The Hartford.

I understand and agree that insurance will go into effect and remain in effect only in accordance with the provisions, terms and conditions of the insurance policy. I understand and agree that only the insurance policy issued to my employer can fully describe the provisions, terms, conditions, limitations and exclusions of my insurance coverage. In the event of any difference between the enrollment form and the insurance policy, I agree to be bound by the insurance policy.

If I have life insurance coverage with The Hartford, I understand and agree that my life insurance benefit(s) reduce at a specified age(s) stated in the policy. If I have disability income coverage with The Hartford, I understand and agree that the maximum duration of benefits payable will be limited to a specified period which may start at a specified age and that a claim for benefits may not be approved for a pre-existing condition.

I authorize payroll deductions from my wages to cover my cost of coverage when applicable.

I understand that no insurance will be valid or in force if I am not eligible in accordance with the terms of the group policy as issued to my employer. I acknowledge and agree that if group participation requirements are required by The Hartford or by law and are not met, the policy will not be implemented and the coverage I have elected will not be in force.

Fraud Notice(s) For Residents of Louisiana and Maryland: Any person who knowingly (knowingly and willfully in Maryland) presents a false or fraudulent claim for payment of a loss or benefit or knowingly (knowingly and willfully in Maryland) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

For Residents of New York (Not applicable to Life Insurance): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

For Residents of Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

EMPLOYEE SIGNATURE

DATE

The HartfordÂŽ is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies is Simsbury, CT Page 3 of 3 Version 4.2013

No enrollment form needed.

San Ramon Valley Fire Protection District is excited to announce that effective January 1, 2017 we will provide a new employee assistance program through CONCERN: EAP. This benefit is FREE to you and your immediate family to help you deal with personal situations that may affect your health and well-being.

CONCERN: EAP provides services from experienced counselors in the community.

They offer short-term counseling for problems such as marriage and family relationships, alcohol/drug abuse, stress, anxiety and depression. Counselors can also make referrals to community resources for special services.

CONCERN can also help you find personal resources and referrals for legal or financial problems, finding sitters or daycare providers, managing debt, tax questions, providing eldercare resources, etc.

CONCERN also has excellent online resources to help you deal with everyday challenges including stress, anger and sleep at the Resilience HubTM, a mobilefriendly website with self-help content to boost mental, emotional and physical well-being in times of stress and change. Click www.concernresiliencehub.com to take a look around for yourself. (You will need to enter an organizational log in.

Just enter “Sungevity” for full access.)

We encourage you to take advantage of this valuable benefit. CONCERN services are confidential and voluntary. If you need more information, please contact the Human Resources Department.

Transition of Care If you are currently seeing a counselor through our current EAP and have remaining EAP visits after December 15, 2016, please call CONCERN at 800-3444222 and ask to speak with a clinical manager regarding your transition of care.

CONCERN’s clinical manager will work with you and your counselor to ensure that you receive the highest level of care and a smooth transition. We encourage you to call CONCERN right away so that they can make arrangements with you for continued care. Confidentiality will be maintained.

SAN RAMON VALLEY FIRE PROTECTION DISTRICT Services are available to all full-time, part-time employees working 30 hours or more per week, retirees, and to their spouse/domestic partner and dependent children up to age 26.

COUNSELING BENEFITS

FINANCIAL COACHING

ONLINE RESOURCES

CONCERN offers assessment, crisis intervention, referrals, and confidential short-term counseling for help with personal issues. Up to 8 visits, per problem, per year with a skilled CONCERN counselor.

Get sound financial guidance to help you manage money wisely and develop long-term financial security. Referral includes up to two 30-minute telephone consultations. Example topics:

CONCERN offers a variety of self-help tools and resources to help you enhance productivity, resilience, and well-being.

• Difficulty with relationships • Emotional distress • Job stress • Communication/conflict issues

• Alcohol or drug problems • Loss and death PARENTING & CHILDCARE Referral available to quality providers for a variety of services, including: • Family day care homes • Infant centers & preschools • Adoption assistance • Before/after school care • In-home childcare • 24-hr care

• School age & college assistance • Complimentary New Baby Kit

• Money management • Debt management • Identity theft resolution • Tax issues

LEGAL CONSULTATION We can link you to a local attorney for a free 30-minute office or telephone consultation for legal issues not related to employment.

These may include: • Estate planning • Wills and living trusts • Landlord-tenant matters • Immigration • IRS matters • On-line legal forms

ELDERCARE RESOURCES We’ll help you find the most appropriate resources to help you care for an elderly or disabled relative. A complimentary copy of How to Care for Aging Parents is available upon request.

www.concern-eap.com

Useful information and links regarding a wide variety of services and topics.

Log on to CONCERN’s homepage and click on “Employee Guide” for access to the following sites:

Resilience HubTM

Curated self-help content to help you deal with life’s challenges and boost your mental, emotional, and physical well-being in times of stress and change.

LifeAdviser

A wealth of articles, tools, forms, and courses to help you enhance your professional and personal success.

NOTE: The first time you access Resilience HubTM or LifeAdviser you will need to enter your company code SRVFPD.

DISTRICT POLICIES & OTHER INFORMATION Please read this information carefully and sign the Receipt of Administrative Policies form.

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Rules of Conduct – Administrative Policy 510 Protected Health Information (HIPPA) – Policy GEN Anti-Harassment – Administrative Policy 321 Employee Relations – Administrative Policy 312 Prohibiting Workplace Violence – Administrative Policy 322 Anti- Discrimination (DFEH – 151) (handout) Sexual Harassment (DFEH-185) (handout) California Family Rights Act (CFRA) Family Medical Leave Act (FMLA) Notification Workers’ Compensation Information

RECEIPT FOR ADMINISTRATIVE POLICIES

I have received and reviewed a copy of the following San Ramon Valley Fire Protection District Administrative Policies: • • • •

Doc. #510 Policy # GEN Policy # 321 Policy # 322

Rules of Conduct Protected Health Information (HIPAA) Anti-Harassment Prohibiting Workplace Violence

In addition, I have received and reviewed the following Department of Fair Employment and Housing information pamphlets: • •

DFEH-151 DFEH-185

Discrimination is Against the Law Sexual Harassment

I have read this information, understand the contents, and agree to abide by the legal regulations in addition to District policies.

Date

Signature

Print Name

Emp.#

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ADMINISTRATION – POLICY AND PROCEDURE TOPIC:

Protected Health Information (HIPAA)

EFFECTIVE DATE: CROSS REF:

01/01/10

DOC NO:

GEN

INTRODUCTION The Standards for Privacy of Individually Identifiable Health Information (“Privacy Rule”) established a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services (“HHS”) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). The HIPAA Privacy Rule protects all “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information “protected health information” (“PHI”).

PURPOSE The San Ramon Valley Fire Protection District (SRVFPD) has specific obligations as required by the HIPAA Privacy Rule. This policy establishes the requirements and best practices for SRVFPD personnel to follow to ensure Privacy Rule compliance.

SCOPE This policy applies to all employees (paid and volunteer) of the SRVFPD. POLICY The SRVFPD has developed and maintains Privacy Practices for the protection of PHI. All individuals who receive medical assessment or treatment from SRVFPD personnel shall be provided with a copy of the SRVFPD’s Privacy Practices, receipt of which is acknowledged by the patient’s signature on the SRVFPD’s Ambulance Billing Authorization and Privacy Acknowledgement.

Management and control of PHI which is used for approved purposes, including patient care documentation as required by Contra Costa County Emergency Medical Service Policy No. 27 shall be compliant with HIPAA in that the PHI shall be protected from unauthorized disclosure by: 1. Maintenance of business associate agreements with entities with which the SRVFPD is authorized to share a patient’s PHI 2. Covering or securing PHI while it is being used by SRVFPD personnel for the purposes of patient care documentation, bill processing or authorized disclosure activities AUTHOR: Kathleene Eubanks, Senior Office Assistant REVIEWED: Bryan Collins, Assistant Chief - Operations APPROVED: Richard Price, Fire Chief ORIGIN DATE: 12/1/09 REVISED DATE:

Page 1 of 4

ADMINISTRATION – POLICY AND PROCEDURE TOPIC:

Protected Health Information (HIPAA)

EFFECTIVE DATE: CROSS REF:

01/01/10

DOC NO:

GEN

3. Segregating PHI from other documents by placing PHI in specially designated privacy envelopes for transmittal, if required, to the SRVFPD’s Emergency Medical Services Division for processing 4. Storage of paper PHI for a period of not less than seven years in a secured storage facility, access of which is limited to authorized personnel 5. Storage of electronic PHI in password protected computers 6. Shredding of PHI older than seven years, which is conducted at a SRVFPD facility and supervised by an authorized SRVFPD employee 7. Electronic transmission to the SRVFPD’s contracted billing service via a secure, independent web site.

Disclosure of PHI shall only be allowed if authorized by the patient, or as documented by the SRVFPD’s Privacy Practices in adherence with HIPAA allowable disclosures. All disclosures are documented in a Record Distribution Report, which is maintained by the SRVFPD’s Emergency Medical Services Division. Patients may obtain information regarding the use and disclosure of their PHI as set forth in the SRVFPD’s Notice of Privacy Practices.

A. PRIVACY OFFICER DESIGNATION In compliance with the HIPAA Privacy Rule the SRVFPD has a designated Privacy Officer, which is the SRVFPD’s Emergency Medical Services (EMS) Coordinator. In the absence of the designated Privacy Officer, questions, concerns, reports or comments regarding PHI or HIPAA compliance should be directed to alternate personnel in the following order: Senior Office Assistant-Operations/EMS EMS Training Specialist Battalion Chief of Special Operations On-duty Battalion Chief B. PRIVACY RULE TRAINING All SRVFPD personnel are required to undergo Privacy Rule training as scheduled by the Privacy Officer in accordance with the HIPAA Privacy Rule within a reasonable time upon association with the SRVFPD. New personnel are not assigned to positions in which they generate or handle PHI until they have received Privacy Rule training.

All personnel will be required to undergo additional training as scheduled by the Privacy Officer within a reasonable time should subsequent material changes to the HIPAA Privacy Rule and/or SRVFPD policies and procedures regarding privacy practices occur.

All Privacy Training will be conducted in a manner designated by the Privacy Officer.

AUTHOR: Kathleene Eubanks, Senior Office Assistant REVIEWED: Bryan Collins, Assistant Chief - Operations APPROVED: Richard Price, Fire Chief ORIGIN DATE: 12/1/09 REVISED DATE:

Page 2 of 4

ADMINISTRATION â&#x20AC;&#x201C; POLICY AND PROCEDURE TOPIC:

Protected Health Information (HIPAA)

EFFECTIVE DATE: CROSS REF:

01/01/10

DOC NO:

GEN

C. ELECTRONIC PATIENT CARE REPORT (PCR) 1. All preparatory documentation and paper signature forms used by SRVFPD personnel to assist in the creation or modification of a PCR is considered PHI and is the sole property of the SRVFPD. 2. All SRVFPD personnel that may be required to complete a PCR will be given a password to access the PCR software on the SRVFPD secure server. This number is unique to the individual. The Human Resources Generalist is the sole holder and distributor of these numbers.

3. No SRVFPD personnel may disclose his/her password.

4. SRVFPD personnel are to access only his/her PCR and associated PHI unless directed otherwise by the Privacy Officer or as permitted by SRVFPD policy for compliance or quality improvement purposes.

5. Printed PCRs and their associated PHI are to be placed in a secure location when not being used. A specially designated privacy envelope shall be used for this purpose when any of these items are not in the possession or control of the person that prepared the information.

6. All scratch paper or draft PCR paperwork used by SRVFPD personnel in the preparation of a PCR must be shredded immediately after the PCR is completed.

7. SRVFPD personnel may not retain any PHI other than for purposes of completing the required PCR, after which time the PHI is transmitted in the specially designated privacy envelopes to the SRVFPDâ&#x20AC;&#x2122;s EMS Division for processing.

D. ACCESS TO PHI Access, disclosure and use of PHI will be to the extent necessary to meet activities authorized by the HIPAA Privacy Rule.

Patients may exercise their rights to access, amend, restrict, and request an accounting, as well as lodge a complaint with either the SRVFPD or the Secretary of the HHS. E. INCIDENTAL DISCLOSURES The Privacy Rule is not intended to impede common practices that are essential in providing health care to the individual. Incidental disclosures are inevitable, but these will typically occur in radio or face-to-face conversation between health care providers. Incidental disclosures should be kept to a minimum and related to required patient care practices.

AUTHOR: Kathleene Eubanks, Senior Office Assistant REVIEWED: Bryan Collins, Assistant Chief - Operations APPROVED: Richard Price, Fire Chief ORIGIN DATE: 12/1/09 REVISED DATE:

Page 3 of 4

ADMINISTRATION â&#x20AC;&#x201C; POLICY AND PROCEDURE TOPIC:

Protected Health Information (HIPAA)

EFFECTIVE DATE: CROSS REF:

01/01/10

DOC NO:

GEN

F. PENALTIES FOR HIPAA VIOLATION There are significant legal penalties against agencies and individuals that do not adhere to the HIPAA Privacy Rule. Failure of SRVFPD personnel to comply with this policy could result in penalties against the SRVFPD and discipline against the individual(s).

AUTHOR: Kathleene Eubanks, Senior Office Assistant REVIEWED: Bryan Collins, Assistant Chief - Operations APPROVED: Richard Price, Fire Chief ORIGIN DATE: 12/1/09 REVISED DATE:

Page 4 of 4

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Harassment and discrimination in employment, housing, public accommodations, and services are against the law.

Department of Fair Employment and Housing

Hate Violence

and Housing Commission or in civil court. If the Commission or a court decides in favor of the

Under the Ralph Civil Rights Act, it is against the

complaining party, the following remedies can be

law for any person to threaten or commit acts of

ordered:

violence against a person or property based on race, color, religion, ancestry, national origin, age, disability, gender, sexual orientation, political affiliation, or position in a labor dispute.

Filing a Complaint If you believe you are a victim of illegal discrimina-

• Award of the job or the housing denied to the complainant, or similar relief • Back pay or promotion for the complainant, or compensation for moving and relocation • Compensatory damages for the complainant, including emotional distress damages • Fines, penalties, or punitive damages

Discrimination is Against the Law Civil Rights in California The Department of Fair Employment and Housing (DFEH) enforces California state laws that prohibit harassment and discrimination in employment, housing, and public accommodations and that provide for pregnancy

tion or hate violence, you can file a complaint with

leave and family and personal medical leave.

DFEH by following these steps:

It also accepts and investigates complaints alleging hate violence or threats of hate violence.

. Contact us at (800) 884-1684 (employment, public accommodation, and hate violence) and

(800) 233-3212 (housing) • Be prepared to present specific facts about the alleged harassment, discrimination, or denial of leave • Provide copies of documents that support the charges in the complaint

For more information, contact DFEH toll free at

(800) 884-1684 (employment, public accommodation, and hate violence)

complaint, such as paycheck stubs, rent materials

and denial of leave complaints

TTY number at (800) 700-2320 or visit our web site at www.dfeh.ca.gov In accordance with the California Government Code

• Prosecuting violations of the law • Educating Californians about the laws

cassette as a disability-related reasonable

We are iiot an advocate for either the person

discuss how to receive a copy of this publication in an alternative format, please contact DFEH at the numbers

by providing written materials and participating in seminars and conferences

Discrimination in Employment The California Fair Employment and Housing

the complaint.

Act (FEHA) prohibits harassment and

If a voluntary settlement cannot be reached, and

discrimination in employment based on the

there is sufficient evidence that establishes a and litigate the case before the Fair Employment

prohibiting harassment and discrimination

above.

if possible, try to assist both parties to resolve

violation of the law, DFEH may issue an. accusation

complaints involving alleged violations of the laws enforced by DFEH

available in Braille, large print, computer disk, or tape accommodation for an individual with a disability. To

We represent the State of California. DFEH will,

• Assisting parties to voluntarily resolve

and ADA requirements, this publication can be made

DFEH will conduct an impartial mvestigation. complaining or the person complained against.

DFEH enforces these laws by • Investigating harassment, discrimination,

(800) 233-3212 (housing)

• Keep records and documents about the receipts, membership applications, and other

What DFEH Does

following: State of California Department of Fair Employment & Housing DFEH-151 (04/04)

• Race

• Color

'^K.

The mission of the Department of Fair. Employment and Housing is to protect the people of California from unlawful discrimination in employment, housing and public accommodations, and from the perpetration of acts of hate violence.

• Religion • Sex (gender) • Sexual orientation

• Marital status • National origin (including language use restrictions) • Ancestry

• Disability (mental and physical, including

HIVandAIDS) • Medical condition (cancer/genetic characteristics)

• Age (40 and above)

• Guaranteed leaves for the birth or adoption of a child; for the employees own serious health condition; or to care for a parent, spouse, or

child with a serious health condition • Protected from harassment because of their sex, race, or any other category covered under the law • Protected from retaliation for filing a complaint with DFEH, for participating in the investigation of a complaint, or for protesting possible violations of the law California workers with disabilities are also entitled to reasonable accommodation when necessary in order to perform the job.

• Request for family care leave • Request for leave for an employee's own serious health condition • Request for Pregnancy Disability Leave • Retaliation for reporting patient abuse in tax-supported institutions

Discrimination is prohibited in all employment practices, including the following: • Advertisements • Applications, screening, and interviews • Hiring, transferring, promoting, terminating, or separating employees • Working conditions • Participation in a training or apprenticeship program, employee organization, or union California workers are • Guaranteed leaves if disabled because of pregnancy • Guaranteed reasonable accommodation for pregnancy

Discrimination in Housing FEHA also prohibits discrimination in the rental and sale of housing based on the following:

Discrimination is prohibited in all aspects of the housing business, including, but not limited to: • Advertisements » Mortgage lending and insurance • Application and selection processes • Terms, conditions, and privileges of occupancy, including freedom from harassment • Public and private land-use practices, including the existence of restrictive covenants Persons with disabilities are entitled to reasonable accommodation in rules, policies, practices,

and services and are also permitted, at their own expense, to reasonably modify their dwelling to ensure full enjoyment of the premises.

As in employment discrimination law, persons are protected from retaliation for filing complaints.

• Race

Discrimination in Public Accommodations

• Color

and Services

• Religion • Sex (gender) • Sexual orientation

Discrimination in public services and accommoda-

tions is prohibited under the Unruh Civil Rights Act. The law requires "full and equal accommodations,

• Marital status

advantages, facilities, privileges, or services in all

• National origin (including language use

business establishments." Business establishments

restrictions) • Ancestry

• Familial status (households with children under age 18) • Source of income*

• Disability (mental and physical, including

HIV and AIDS) • Medical condition (cancer/genetic characteristics) . Age *Until 12/31/04 unless extended by statute.

covered by the law include, but are not limited to: • Hotels and motels • Nonprofit organizations • Restaurants

• Theaters < Hospitals • Barber shops and beauty salons • Housing accommodations • Local government and public agencies • Retail establishments

03 m:^

IS3

The definition of sexual harassment includes many forms of offensive behavior.

'JSfc

^^

fc;Y Department of Fair Employment and Housing

such as a lead, supervisor, manageroragent; • the employer had no knowledge of the harassment; • there was a program to prevent harassment; and • once aware of any harassment, the employer took immediate and appropriate corrective

Employees can also pursue the matter through a private lawsuit in civil court after a complaint

Sexual Harassment

has been filed with DFEH and a Right-to-Sue

The Facts About Sexual Harassment

Notice has been issued.

TheFairEinployment and Housing Act (FEHA)

For more information, see publication DFEH-159

defines sexial harassment as harassment

"Guide for Complainants andRespondents."

based on sex or of a sexual nature; gender harassment; and harassment based on pregnan-

action to stop the harassment.

cy, childbirth, or related medical conditions.

The definition of sexual harassment includes

Filing a Complaint

many forms of offensive behavior, including

Employees or job applicants who believe that they

harassment of a person of the same gender

havebeen sexually harassed may file acomplaint of

as the harasser. The following is apartial list of

discrimination with DFEH within one year ofthe

types of sexual harassment:

harassment.

• Unwanted sexual advances DFEH selves as aneutral fact-fmder and attempts to help theparties voluntarily resolve disputes.

IfDFEH fmds sufficient evidence to establish that discrimination occurred and settlement efforts fail, the Department may file a civil complaint in stateor federal court on behalf ofthe co mplaining party. The DFEH may seekpunitivedamagesis entitledto attorney's fees and costs if it prevails in litigation.

Remedies include: • Fines or damages for emotional distress

• Offering employment benefits in For more information, contact DFEH toll free at

(800) 884-1684

exchange forsexual favors • Actual or threatened retaliation

TTY number at (800) 700-2320 or visit our Web site at www.dfeh.ca.gov

Inaccordawe with the California Government Code and ADA recfiwemenls, this publication can be made cmailable in Braille, large print, computer disk, ortape cassette as a disa.bility-related reasonable accommodation for an

hvlividwlwith a. disability. To discuss how to receive a copy of this publication in an alternative format, -please contact DFEHat the numbers above.

• Leering; making sexual gestures; or display ing sexually suggestiveobjects, pictures, cartoons, orposters

• Making or using derogatory comments, epithets, slurs, orjokes • Sexual comments including graphic com-

from each employer or person found to have

ments about an individual's body; sexu-

violated the law

ally degrading words used to describe an individual; orsuggestive orobscene letters,

• Hiring or reinstatement • Back pay or promotion • Changes in thepolicies or practices ofthe

notes, or mvitations

State ofCalifornia Department of Fair Employment & Housing

mvolved employer DFEH-185 (11/14)

• Phy sical touching or as sault, as well as impeding or blocking movements • Sexual desire is not necessary

The mission of the Department of Fair Employment and Housing is to protect the people of California from unlawful discrimination in employment, housing and public accommodations, and from the perpetration of acts of hate violence.

Employers' Obligations All employers must take the following actions against harassment: • Take all reasonable stepsto prevent discrimination and harassment from occurring. If harassment does occur,

take effective action to stop any farther harassmentandto correct any effects of the harassment.

• Develop and implement a sexual harassment prevention policy with a procedure for employees to make complaints and for the employerto investigate complaints.

Policies should include provisions to: • Fully inform the complainant of his/herrights and any obligations to secure those rights.

• Fully and effectively investigate. Theinvestigation must be thorough, objective, and

plainant that action has been taken to stop the

• A program to eliminate sexual harassment from

harassment from recurring. Finally, appropriate

the workplace is not only required by law, but is

steps must be takento remedy the complainant's

themost practical way foran employer

damages, if any.

to avoid or limit liability if harassment should

Post the Department of Fair Employment and

occurdespite preventiveefForts.

Housing (DFEH) employment poster (DFEH - 162) in the workplace (available through the DFEH publications line [916] 478-7201 or Web site). ' Distribute an information sheet on sexual harassment to all employees. An employer may

either distribute this pamphlet (DFEH 185) or develop an equivalent document that meets the requirements of Government Code section

12950(b). This pamphlet may be duplicated in

Employer Liability All employers,regardless ofthe number of employees, are covered by the harassment section ofthe FEHA. Employers are generally liable for harassment by their supervisors or agents. Harassers, including both supervisoiy and non-supervisory personnel, may be held personally liable for harassing an employee or coworker or for aiding and abetting harassment.

Additionally, the law requu-es employers to take

any quantity. However, this pamphlet is

"all reasonable stepstopreventharassmentfi-om

not to be used in place of a sexual harassment

occurring." If an employer has failed to take such

prevention policy, which all employers are

preventive measures, that employer can be held li-

required to have.

able for the harassment. A victim may be entitled to

' All employees should be made aware ofthe

damages, even though no employment opportunity has been denied and there is no actual loss o'fpay or

complete. Anyone with information re-

seriousness of violations ofthe sexual harassment

gardingthe matter should be interviewed.

policy and must be cautioned against usingpeer

A determination must be made and the re-

pressure to discourage harassment victims

In addition, if an employer lcnows or should have

suits communicated to the complainant,

from complaining.

known that a non-employee (e.g. client or custom-

to the alleged harasserand, as appropriate, to all others directly concerned.

• Take prompt and effective corrective action if the harassment allegations are proven. The employer must take appropriate action to stop the harassment and ensure it will not continue. The employer must also communicate to the com-

' Employers who do business in California and employ 50 or more part-time or full-time employees T-nust provide at least two hours of sexual harassment training every two years to each supervisory employee and to all new supervisory employees within six months of theu- assumption ofa supervisory position.

benefits.

er) has sexually harassed an employee, applicant, or person providing services forthe employer and fails to take mmediate and appropriate corrective action, the employer may be held liable forthe actions ofthe non-employee.

An employer might avoid liability if • the harasseris not in a position ofauthority,

Provisions cover employers who do business

in California and employ 50 or more part-time or full-time people.

'

Contact DFEH by calling the toll-free number

California Family Rights Act

at (800) 884-1684 to schedule an appointment.

.

Be prepared to present specific facts about

the alleged discrimination or denial of leave.

.

The Føir Employment and Housing Act,

Keep records and provide copies of docu-

enforced by the Department of Fair

ments that support the charges in the complaint, such as paycheck stubs, calendars,

Employment and Housing (DFEH), contains family care and medical leave provisions for

correspondence, and other potential proof

California employees. These leave provisions,

of discrimination.

known asthe Caliþrnia Family Rights Act (CFRA), cover employers who do business in California and employ 50 or more parttime or full-time people.

Complaints must be filed within one year of the last act of discrimination.

DFEH will conduct an impartial investigation.

We are not an advocate for either the person complaining or the person complained against.

We represent the State of California. DFEH

will, if possible, try to the complaint.

assist both parties to resolve

If a voluntary settlement cannot be reached, and there is sufficient evidence to establish

a

violation

of the law, DFEH may issue an accusation and litigate the case before the Fair Employment and Housing Commission or in civil court. If the

For more information, contact DFEH toll free at

(800) 884-1684

AII such employers must provide information about the CFRA provisions to their employees and post this information in a conspicuous place where employees tend

TTY number at (800) 700-2320 or visit our web site at www.dfeh,ca.gov

to gather. Employers who provide employee

In accordance with the Caliþrnia Goyernment Code and ADA requirements, thìs publication can be made available in Braille, Iarge print, computer disk, or tape cassette as a disability-related reasonable øccommodation for an individual with a disabíIity. To discuss how to receive a copy of this publication in an alternatite format, please contact DFEH at the numbers aboye.

handbooks must include information about CFRA leave in the handbook.

CFRA Leave Requirements

.

employee must have more than

Commission or a court decides in favor of the complaining part¡ remedies may include reinstatement, back pay, reasonable attorney's fees, damages

12

months of service with the employer and have worked at least 1,250 hours

for that employer in the l2-month

for emotional distress, and

administrative fines.

To be eligible for CFRA leave, an

State of California Department of Fair Employment & Housing DFEH-1

88 (04/04)

period before the leave begins.

.

An eligible employee may take an unpaid leave to bond with an adopted

IrìL

:¡lFú.-The mission of the Department of Fair Employment and Housing is to protect the people of

California from unlawful discrimination in employment, housing and public accommodations, and

from the perpetration of acts of hate violence,

.

or foster child or to bond with a

leave and the probable

newborn.

condition.

An eligible CFRA employee may take unpaid

.

leave to care for a parent, spouse,

have under PDL. Leave taken for the

tìe

.

.

Full-time employees may take leave of up to 12 work weeks in a l2-month

within one year of the event.

.

period. Part-time employees may take

In addition to the family care and medical leave requirements of the CFRA, employers of five or more persons have additional

leave on a proportional basis. The

obligations pertaining to PDL. Please refer to

leave does not need to be taken in one

the DFEH publication "Facts on Pregnancy

continuous period of time.

Disability Leave" for more information.

An employer may require a3\-day advance notice of the need for a CFRAqualifying leave. When this is not

Salary and Benefits During CFRA Leave

After CFRA leave, employees are guaranteed a

return to the same or comparable position

and can request the guarantee in writing.

' If the same position is no longer available, such as in a layoffor closure, the employer

must offer a position that is comparable in terms of pay,location, job content, and promotional opportunities, unless the employer can prove that no comparable position exists. An employee is not entitled to reinstatement if the employee would have been otherwise laid off or terminated.

Employers are not required to pay employees

Family Tem porary Disahility Insurance F|DI) or "Paid Family Leave"

possible due to the unexpected nature

during a CFRA leave. An employer may

Employees on CFRA leave of absence may also be

of the leave, notice should be given

require an employee to use accrued vacation

eligible for six weeks of paid leave under FTDI, a

as soon as practicable. Notice can be

time or other accumulated paid leave other

program administered by the California Employ-

written or verbal and should include the timing and the anticipated duration of

than sick time.

the leave. An employer must respond to

the use of sick time can be required.

a leave request

.

birth

or adoption of a child must be completed

employee's own serious health condition.

Return Rights After CFRA Leave

.

Employees are entitled to take CFRA leave in

addition to any leave entitlement they might

or child with a serious health condition.

CFRA leave may also be taken for

duration of the

within

10 calendar days.

.

lf the CFRA leave is for the

employee's own serious health condition,

. If the employer provides health benefits

ment Development Department (EDD). For

further information, contact the EDD at (800) 480-3287 or visit the web site at www.edd.ca.gov.

The employer may require written

under a group plan, the employer must

Filing a Complaint

communication from the health-care provider ofthe child, parent, spouse,

continue to make these benefits available

If you believe your CFRA.rights have been

during the leave. The employee is also entitled to accrual of seniority and participation in other benefit plans.

violated, you can explore filing a complaint with

or employee with a serious health condition stating the reasons for the

DFEH by following these steps:

California Department of Fair Employment & Housยกng

Fact Sheet General lnformation about the Galifornia Family Rights Act California Government Code sections 12945.1 and 12945.2 of the Fair Employment and Housing Act (FEHA) contain provisions relating to family care and medical leave entitlement.

The Fair Employment and Housing Commission's (FEHC) interpretation of these provisions is contained in Section 7297.0 of the California Code of Regulations. ln addition to the family care and medical leave requirements of the FEHA, employers of five or more persons have additional obligations pertaining to pregnancy disability leave.

The federal Family and Medical Leave Act (FMLA) also ensures family care or medical care leave entitlement (29 USC sections 2601 et seq. lmplementing regulations are contained in 29 CFR Part 825). The FMLA is enforced by the Wage and Hour Division of the U.S. Department of Labor. The CFRA and pregnancy disability leave provisions of state law are enforced by the Department of Fair Employment and Housing (DFEH). Where differences between federal and state law exist, employers should comply with those provisions that are most beneficial to the employee.

This fact sheet addresses the most frequently asked questions regarding family care or medical leave entitlement.

ELIGIBILITY REQUIREMENTS

For what reasons may an employee take a CFRA leave?

An employee may take an unpaid leave for the birth of a child for purposes of bonding, for placement of a child in the employee's family for adoption or foster care, for the serious health condition of the employee's child, parent or spouse, and for the employee's own serious health condition.

What is a serious health condition?

Serious health condition means illness, injury (including on-the-job-injuries), impairment, or physical or mental condition of the employee or a child, parent or spouse of the employee that involves either (1) inpatient care (i.e., an overnight stay) in a hospital, hospice, or residential care facility or (2) continuing treatment or supervision by a health-care provider.

California Family Rights Act - Page 1 of 5

May an employer require a written medical certification of the serious health condition of the employee, employee's child, parent orspouse before granting the leave?

Yes. The employer may require written communication from the health-care provider of the child, parent, spouse, or employee with a serious health condition. Ceftification is sufficient if it includes (1) the date on which the serious health condition commenced, (2) the probable duration of the condition, (3) an estimate of the amount of time the employee needs to care for the sick family member, (4) a statement that the serious health condition warrants participation of a family member to provide care during the period of treatment or medical supervision, or (5) a statement that the employee, due to the serious health condition, is unable to perform one or more of the essential functions of his or her job

May an employee take a CFRA leave due to childbirth, or related medical condition?

a disability related to her pregnancy,

No. An employee has no right to a CFRA leave for a disability related to pregnancy, childbirth, or related medical condition. Separate leave entitlement is provided by the FEHA's pregnancy leave provisions covered in Government Code section 12945.2(b)(2). Under the FMLA, however, a pregnancy disability qualifies as a serious health condition and runs concurrently with California pregnancy disability leave.

What employers are covered under the CFRA? Employers subject to the CFRA are those who do business in California and employ 50 or more part-time or full{ime employees in any state. Covered employers include non-profit, religious organizations, the State of California, including any political and civil subdivision of the state and cities, regardless of the number of employees.

What requirements must an employee satisfy to be eligible to take a CFRA leave?

To be eligible for a CFRA leave, an employee must be either a full{ime or part-time employee working in California, have more than 12 months (52 weeks) of service with the employer, have worked at least 1,250 hours in the 12-month period before the date the leave begins, and work at a location in which the employer has at least 50 employees within 75 miles of the employee's work-site.

LEAVE REQUIREMENTS What is the maximum CFRA leave entitlement?

Leave may total up to 12 workweeks in a 12-month period. lt does not need to be taken in one continuous period of time.

How is the 12-month period calculated?

An employer may choose how to compute the 12-month period in which lhe 12 work weeks of leave entitlement occurs using any of the four calculation methods allowed under the federal California Family Rights Act - Page 2 of 5

FMLA regulations listed below. An employer must, however, apply the chosen method consistently and uniformly to all employees.

These methods are

1. The calendar

2.

3.

4.

year;

Any fixed "leave year" of 12 months, such as a fiscal year or a year starting on an employee's anniversary date; The 12-month period measured from the date an employee's first FMLA/CFRA leave begins; or A rolling 12-month period measured backward from the date an employee uses any leave.

To how much leave are the CFRA-eligible employees entitled? What if employees work more or less than five days per week or work alternative work schedules?

The leave entitlement is 12 work weeks or 60 work days for full-time employees working a fiveday, eight-hours-a-day work week during a 12-month period. For eligible employees who work more or less than five days a week or who work on alternative work schedules, the number of working days that constitute 12 workweeks is calculated on a pro rata or proportional basis.

May the CFRA leave be added onto other forms of leave?

Yes. At the end of an employee's period(s) of pregnancy disability leave, a CFRA-eligible employee may request a CFRA leave of up to 12 work weeks for reason of the birth of her child, if the child has been born by this date. There is no requirement that either the employee or child have a serious health condition. Nor is there a requirement that the employee no longer be disabled by her pregnancy, childbirth, or related medical condition before taking a CFRA leave for reason of the birth of her child.

Is there a minimum duration for a CFRA leave taken for the birth, adoption, or fostercare placement of a child?

Yes. The basic minimum duration of a CFRA leave is two weeks when the leave is taken for the birth, adoption, or foster-care placement of a child. However, an employer shall grant a request for CFRA leave of less than two-week duration on any two occasions. ln addition, leave taken for the birth, adoption, or foster-care placement of a child must be completed within one year of the qualifying event.

ls there a minimum duration for a CFRA leave taken for the serious health condition of a parent, child, or spouse or for the serious health condition of the employee?

No. Where CFRA leave is taken for the serious health condition of a parent, child, or spouse or for the serious health condition of the employee, leave may be taken intermittently or on a reduced work schedule when medically necessary, as determined by the health care provider of the person with the serious health condition. However, an employer may limit leave increments to the shortest period of time the employer's payroll system uses to account for absences.

California Family Rights Act - Page 3 of 5

Are there any limitations to the CFRA leave entitlement?

Yes. lf both parents are eligible for the CFRA leave but are employed by the same employer, that employer may limit leave for the birth, adoption, or foster-care placement of their child to 12 work weeks in a 12-month period between the two parents. No other limitations restrict these parents from taking a CFRA leave for other qualifying reasons.

BENEFITS

Must an employer pay employees during their CFRA leaves?

No. An employer is not required to pay an employee during a CFRA leave, except when an eligible employee elects or the employer requires the employee to use any accrued vacation time or other accumulated paid leave other than accrued sick leave. However, if the CFRA leave is for the employee's own serious health condition, the employee may elect or the employer may require the employee to use any accrued vacation time or other accumulated paid leave, including any accrued sick leave. Additionally, accrued sick leave may be used for a CFRA leave granted for any other reason if mutually agreed to by the employer and employee.

Must an employer continue health care coverage for employees during their CFRA Ieave?

Yes. lf the employer provides health benefits under any group health plan, the employer

has

an obligation to continue providing such benefits during an employee's CFRA leave, a FMLA leave, or both. This obligation commences on the date leave first begins under the FMLA (i.e. for pregnancy disability leave) or under the FMLA/CFRA (i.e. for all other family care or medical leaves). The obligation continues for the duration of the leave(s), up to a maximum of 12 workweeks in a 12-month period.

Must an employer continue other benefits during an employee's CFRA leave?

Yes. During the period of a CFRA leave, the employee is entitled to accrual of seniority and to participate in employee benefit plans, including life, short{erm or long-term disability or accident insurance, pension and retirement plans, and supplemental unemployment benefit plans to the same extent and under the same conditions as would apply to any other leave granted by the employer for any reason other than a CFRA leave.

REINSTATEMENT

Must an employer reinstate the employee at the end of his or her CFRA leave?

Yes. Upon granting an employee a CFRA leave, the employer shall guarantee reinstatement to the same or comparable position and shall provide the guarantee in writing upon the request of the employee. Employment in a comparable position means employment in a position that is virtually identical to the employee's original position in terms of pay, benefits, and working

California Family Rights Act - Page 4 of 5

conditions, including privileges, prerequisites, and status. lt must involve the same or substantially similar duties and responsibilities, skill, effort, and authority, must be performed at the same or geographically proximate work site, and ordinarily means the same shift or same or equivalent work schedule.

Are there any reasons an employer could deny reinstatement to an employee out on a CFRA leave?

Yes. An employer may deny reinstatement to an employee if his or her position ceased

to

exist, such as in a lay-off. An employer may also deny reinstatement if the employee taking the leave is a key employee (salaried and among the highest-paid 10 percent), and the denial of reinstatement is necessary to prevent substantial and grievous economic injury to the operations of the employer. However, the employer must notify the employee of the intent to refuse reinstatement at the time the employer determines the refusal is necessarv, as well as give the employee a reasonable oppoftunity to return to work.

NOTIFICATION

Must an employee give advance notice if he or she wants to take a CFRA leave?

Yes. An employee or employee's spokesperson shall provide at least verbal notice sufficient to make the employer aware the employee needs a CFRA-qualifying leave, state the reason for the leave, and the anticipated timing and duration of the leave. An employer may require 30 days advance notice before a CFRA leave is to begin if the need for the leave is foreseeable. lf 30 days is not practicable (i.e. lack of knowledge of approximately when leave will be required to begin, a change in circumstances, or a medical emergency), notice must be given as soon as practicable. Under all circumstances, it is the employer's responsibility to designate leave, paid or unpaid, as CFRA or FMLA. ln addition, the employer shall respond to a leave request as soon as possible but within ten calendar days after receiving the request.

Must an employer inform employee of notice requirements?

Yes. An employer shall provide notice to his or her employees of the right to request a CFRA leave and shall post the notice in a conspicuous place or places where employees tend to congregate. lf the employer publishes a handbook describing other kinds of personal or disability leaves available to its employees, the employer shall include a description of a CFRA leave in its next edition. The employer may include both pregnancy disability leave and the CFRA leave requirements in a single notice.

For more information, contact the Department toll free at: (800) 884-1684 Sacramento area & out-of-state: (91 61 227 -0551 or visit our website at: www.dfeh.ca.gov

TTY Number: (800) 700-2320

This publication can be made available in Braille, large print, computer disc, and tape cassette.

DFEH-188 (6/98)

California Family Rights Act - Page 5 of 5

U.S. Department of Labor V/age and Hour Division

HE

U,S, Wage rnd Hour f)ivision

(Revised February 20 t0)

Fact Sheet #282 The Famity and Medicat Leave Act of lgg3 Notice: On October 28,2009, the President signed the National Defense Authorization Act for Fiscal Year 2010 (2010 NDAA), Public Law 111-84. Section 565 of the 2010 NDAA amends the military family leave entitlements of the Family and MedicalLeave Act (FMLA). These amendments expand coverage for "qualifl,ing exigency" leave to eligible employees with covered family members in the Regular Armed Forces and coverage for "military caregl ver leave" to elig ble employ ees who afe the spouse, son, daughter parent, or next of kin of certain veterans wl th a SETl ous mJ ury of illness On December 2 1 2009 , the Presi dent signed the Air line Flight Crew T echnical Corrections Act, Public Law 1 I I 1 9 ) which modifies the FMLA eli gibility for crew mem bers Thi S F act Sheet does not these amendments to the FMLA a

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The U.S. Department of Labor's Employment Standards Administration, V/age and Hour Division, administers and enforces the Family and Medical Leave Act (FMLA) for all private, state and local government employees, and some federal employees. Most federal and certain congressional employees are also covered by the law and are subject to the jurisdiction of the U.S, Ofhce of Personnel Management or the Congress.

The FMLA entitles eligible employees to take upto 12 workweeks of unpaid, job-protected leave in a l2-month period for specified family and medical reasons, or for any "qualifying exigency" arising out of the factthat a covered military member is on active duty, or has been notified of an impending call or order to active duty, in support of a contingency operation, The FMLA also allows eligible employees to take up to 26 workweeks of job-protected leave in a "single 12-month period" to care for a covered servicemember with a serious injury or illness. See

EMPLOYER COVERAGE The FMLA applies to all public agencies, including state, local and federal employers, local education agencies (schools), and private-sector employers who employed 50 or more employees in20 or more workweeks in the current or preceding calendar year, including joint employers and successors of covered employers.

EMPLOYEE ELIGTBILITY To be eligible for FMLA benefits, an employee must: o work for a covered employer; . have worked for the employer for a total of 12 months; . have worked at least 1,250 hours over the previous 12 months; and . work at a location in the United States or in any territory or possession of the United States where at least 50 employees are employed by the employer within 75 miles.

While the 12 months of employment need not be consecutive, employment periods prior to a break in service of seven years or more need not be counted unless the break is occasioned by the employee's fulfillment of his or herNational Guard or Reserve military obligation (as protected under the Uniformed Services Employmenf and, Reemployment Rights Act (USERRA)), or a written agreement, including a collective bargainingagreement, exists concerning the employer's intention to rehire the employee after the break in service. See *EMLA

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LEAVE ENTITLEMENT A covered employer must grant an eligible employee up to a total of

12 workweeks of unpaid leave during any

12-month period for one or more of the following teasons:

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for the birth and care of a newborn child of the employee; for placement with the employee of a son or daughter for adoption ol foster care; to care for a spouse, son, daughter, or parent with a serious health condition; to take medical leave when the employee is unable to work because of a serious health condition; or for qualifying exigencies arising out of the fact that the employee's spouse, son, daughter, or parent is on active duty or call to active duty status as a member of the National Guard or Reserves in support of a contingency operation.

A covered employer also must grant

an eligible employee who is a spouse, son, daughter, parent, or next of kin of a current member of the Armed Forces, including a member of the National Guard or Reserves, with a serious injury or illness up to a total of 26 workweeks of unpaid leave during a "single l2-month period" to care for the servicemember. Fol specihc information regarding military family leave, see "Fact Sheet #28A The Family and Medical Leave Act Military Family Leave Entitlements."

Spouses employed by the same employer are limited in the amount of family leave they may take for the birth and care of a newborn child, placement of a child for adoption or foster care, or to care for a parent who has a serious health condition to a combined total of 12 workweeks (or 26 workweeks if leave to care for a covered servicemember with a serious injury or illness is also used). Leave for birth and care, or placement for adoption or foster care, must conclude within 12 months of the birth or placement.

Under some circumstances, employees may take FMLA leave intermittently - taking leave in separate blocks of time for a single qualifuing reason - or on a reduced leave schedule - reducing the employee's usual weekly or daily work schedule. 'When leave is needed for planned medical treatment, the employee must make a reasonable effort to schedule treatment so as not to unduly disrupt the employer's operation. If FMLA leave is for birth and care, or placement for adoption or foster care, use of intermittent leave is subject to the employer's approval.

Under certain conditions, employees or employers may choose to "substitute" (run concurrently) accrued paid leave (such as sick or vacation leave) to cover some or all of the FMLA leave. An employee's ability to substitute accrued paid leave is determined by the terms and conditions of the employer's normal leave policy.

"Serious health condition" means an illness, injury, impairment, or physical or mental condition that involves either: a

Inpatient carc (i.e., an overnight stay) in a hospital, hospice, or residential medical-care facility, including any period of incapacity (i.e., inability to work, attend school, or perform other regular daily activities) or subsequent treatment in connection with such inpatient care; or Continuing treatment by a health care provider, which includes: 1) A period of incapacity lasting more than three consecutive, full calendar days, and any subsequent treatment or period of incapacity relating to the same condition that also includes: (

c

treatment two or more times by or under the supervision of a health care provider (i.e.,inperson visits, the first within 7 days and both within 30 days of the first day of incapacity); or

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a

within 7 days of the first day (e.g., prescription medication, physical of incapacity) with a continuing regimen of treatment therapy); or one treatment by a health care provider (i.e., an in-person visit

(2) Any period of incapacity related to pregnancy or for prenatal care. A visit to the health care provider is not necessary for each absence; or (3) Any period of incapacity or treatment for a chronic serious health condition which continues over an extended period of time, requires periodic visits (at least twice ayear) to a health care provider, and may involve occasional episodes of incapacity. A visit to a health care provider is not necessary for each absence; or (4) A period of incapacity that is permanent or long-term due to a condition for which treatment may not be effective. Only supervision by a health care provider is required, rather than active treatment;

or (5) Any absences to receive multiple treatments for restorative surgery or for a condition that would likely result in a period of incapacity of more than three days if not treated.

MAINTENANCE OF HEALTH BENEFITS A covered employer is required to maintain group health insurance coverage for an employee on FMLA leave whenever such insurance was provided before the leave was taken and on the same terms as if the employee had continued to work. If applicable, arrangements will need to be made for employees to pay their share of health insurance premiums while on leave. In some instances, the employer may recover premiums it paid to maintain health coverage for an employee who fails to return to work from FMLA leave.

JOB RESTORATION Upon return from FMLA leave, an employee must be restored to the employee's original job, or to an equivalent job with equivalent pay, benefits, and other terms and conditions of employment. An employee's use of FMLA leave cannot result in the loss of any employment benefit that the employee earned or was entitled to before using FMLA leave, nor be counted against the employee under a "no fault" attendance policy. If a bonus or other payment, however, is based on the achievement of a specified goal such as hours worked, products sold, or perfect attendance, and the employee has not met the goal due to FMLA leave, payment may be denied unless it is paid to an employee on equivalent leave status for a reason that does not qualifr as FMLA leave.

An employee has no greater right to restoration or to other benefits and conditions of employment than if the employee had been continuously employed.

NOTICE AND CERTIFICATTON Emplo)ยกee Notice Employees seeking to use FMLA leave are required to provide 30-day advance notice of the need to take FMLA leave when the need is foreseeable and such notice is practicable. If leave is foreseeable less than 30 days in advance, the employee must provide notice as soon as practicable - generally, either the same or next business day. When the need for leave is not foreseeable, the employee must provide notice to the employer as soon as practicable under the facts and circumstances of the particular case. Absent unusual circumstances, employees must comply with the employer's usual and customary notice and procedural requirements for requesting leave.

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Employees must provide sufficient information for an employer reasonably to determine whether the FMLA may apply to the leave request. Depending on the situation, such information may include that the employee is incapacitated due to pregnancy, has been hospitalized overnight, is unable to perform the functions of the job, and/or that the employee or employee's qualif ing family member is under the continuing care of a health care provider.

When an employee seeks leave for a FMlA-qualifuing reason for the first time, the employee need not expressly asserl FMLA rights or even mention the FMLA. When an employee seeks leave, however, due to a FMlA-qualifying reason for which the employer has previously provided the employee FMlA-protected leave, the employee must specifically reference either the qualiflring reason for leave or the need for FMLA leave.

Emnlov Notice Covered employers must post a notice approved by the Secretary of Labor explaining rights and responsibilities under the FMLA. An employer that willfully violates this posting requirementmay be subject to a civil money penalty of up to $110 for each separate offense. Additionally, employers must either include this general notice in employee handbooks or other written guidance to employees concerning benefits, or must distribute a copy of the notice to each new employee upon hiring. Employers may use the notice prepared by U.S. Department of Labor to meet this requirement.

When an employee requests FMLA leave or the employer acquires knowledge that leave may be for a FMLA purpose, the employer must noti$r the employee of his or her eligibility to take leave, and inform the employee of his/her rights and responsibilities under the FMLA. V/hen the employer has enough information to determine that leave is being taken for a FMlA-qualiflring reason, the employer must notifu the employee that the leave is designated and will be counted as FMLA leave. Employers may use the optional forms wH-3 81 and WH-382 prepared by the U.S. Department of Labor to meet these notification requirements.

Certification Employers may require that an employee's request for leave due to a serious health condition affecting the employee or a covered family member be supported by a certification from a health care provider. An employer may require second or third medical opinions (at the employer's expense) and periodic recertihcation of a serious health condition. An employer may use a health care provider, a human resource professional, a leave administrator, 01 amaĂŽagement official - but not the employee's direct supervisor to authenticate or clari$' a medical certification of a serious health condition. An employer may have auniformly-applied policy requiring employees returning from leave for their own serious health condition to submit a certiftcation that they are able to resume work. If reasonable safety concerns exist, an employer may, under certain circumstances, require such a cerlification for employees returning fiom intermittent FMLA leave. Employers may use the optional forms WH-380-E and WH-380-F prepared by the U.S. Department of Labor for obtaining medical certif,rcations of serious health conditions.

UNLA\MFUL ACTS

It is unlawful for any employer to interfere with, restrain, or deny the exercise of any right provided by the FMLA. It is also unlawful for an employer to discharge or discriminate against any individual for opposin g practice, or because of involvement in any proceeding, related to the FMLA.

any

ENFORCEMENT The V/age and Hour Division investigates complaints. If violations cannot be satisfactorily resolved, the U.S. Department of Labor may bring action in court to compel compliance. Individuals may also be able to bring a private civil action against an employer for violations.

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OTHER PROVISIONS Special rules apply to employees of local education agencies. Generally, these rules apply to intermittent leave or when leave is required near the end of a school term.

Salaried executive, administrative, and professional employees of covered employers who meet the Fair Labor Standards Act (FLSA) criteria for exemption from minimum wage and oveftime under Regulations, 29 CFR Part 547, do not lose their FlSA-exempt status by using any unpaid FMLA leave. This special exception to the "salary basis" requirements for FLSA's exemption extends only to an "eligible" employee's use of leave

required by the FMLA.

For additional information, visit our'Wage and Hour Division'Website: http://www.wagehour.dol.gov and/or call our toll-free information and helpline, available 8 a.m. to 5 p.m. in your time zone, 1 -866-4-US\ryAGE (t-866-487 -9243).

This publication is for general information and is not to be considered in the same light as off,rcial statements of position contained in the regulations.

U.S. Department of Labor Frances Perkins Building 200 Constitution Avenue, NW Washington, DC 20210

1-866-4-USWAGE TTY: 1-866-487-9243 Contact Us

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