Open Enrollment for Health Benefits

For the sixth consecutive year, CPC is pleased to offer two medical insurance plans (one HMO and one PPO) with no monthly premiums for benefited employees for 2020 (pending CPC Board approval). With total annual costs of $3 million, health care insurance represents the largest portion of the employee benefit pool. CPC remains committed to providing options that are fiscally viable for CPC and our employees – including offering health insurance plans with no monthly premium costs.

On an annual basis, corporation-paid medical insurance provides a significant benefit to our employee’s total compensation package – $8,059 for employee only, $16,116 for employee and one dependent, and $20,952 for employee and family. Employer-paid medical insurance alone accounts for a benefit of approximately $4 to $10 per hour for full-time employees!

Have Questions?

If you still have questions, contact Human Resources at 805-756-1121 to answer questions and help.

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Making Changes

During Open Enrollment (Monday, Sept. 9 through Friday, Oct. 4, 2019), you may make changes to the following:

Medical Insurance

CPC Medical Plans and Monthly Premiums for 2020

CPC Medical Insurance Plans – Summary of Covered Services 2020

To change your CalPERS Medical Plan for 2020 and/or to add or drop eligible dependents – complete the HBD-12 and return the completed form to Jill Connelly, [email protected], Building 15, by Oct. 4, 2019.


NOTE: If you want to keep your existing medical insurance plan for 2020, you do not need to do anything (no form required).

Dental and Vision

Contact Jill Connelly at (805) 756-5580, [email protected], by Oct. 4, 2019 to request changes to your dental and/or vision plan (i.e., add or delete an eligible dependent).


If you want to elect for Cash-in-Lieu of health insurance (medical, dental, vision), complete the Cash-in-Lieu form, attach proof of alternate medical insurance, and return to Jill Connelly, [email protected], by Oct. 4, 2019.

Flexible Spending Account/Dependent Care Account (FSA/DCA)

Even if you had an FSA or DCA in 2019, you still need to re-enroll for 2020. To elect an FSA and/or DCA for 2020, complete the FSA/DCA Election Form and the FSA/DCA Enrollment Form 2019, and return the completed forms to Jill Connelly, [email protected], by Oct. 4, 2019. If you are a new enrollee into one of these programs OR you had an FSA or DCA in 2019 but your bank has changed, complete the FSA-DCA Direct Deposit Form (if you want direct deposit for your reimbursements, which is optional).

Life Insurance

To name or change your life insurance beneficiary or to add Optional Life Insurance and/or AD&D, contact Jill Connelly, (805) 756-5580, [email protected]


To enroll in an AFLAC supplement insurance plan, contact our AFLAC representative, Karen Wilson, directly at (805) 423-5671 or email [email protected]

Optional Retirement Plans - Tax Sheltered Annuities (TSA)

CalPERS 457 – To enroll in a 457 plan for the first time, complete the CalPERS 457 Plan Enrollment Form and the CalPERS 457 Plan Beneficiary Designation Form and return to Jill Connelly, [email protected]

To make a change to your existing 457 plan, complete the CalPERS 457 Change Form and return to Jill Connelly [email protected].

403b – To enroll in a 403b plan for the first time and/or make contribution changes to an existing account, complete the 403b Plan Form  and return to Jill Connelly [email protected]

NOTE: You can enroll and/or make contribution changes to your 457 or 403b account at any time – you are not limited to the dates of Open Enrollment.

Forms and Resources

Open Enrollment

Medical Plans and Premiums

Summary of the corporation's three HMO and three PPO plans offered.
Size: 520.35 kb
Hits: 889
Date modified: 12 - 18 - 2019

Summary of medical plan services covered 2020

Summary of the covered services for all of Cal Poly Corporation's medical insurance plans.
Size: 97.80 kb
Hits: 519
Date modified: 09 - 12 - 2019

FSA and DCA Enrollment Form

The enrollment forms for flexible spending and dependent care accounts.
Size: 93.27 kb
Hits: 470
Date modified: 08 - 23 - 2019

CalPERS Health Benefit Summary

Includes summaries of all of CalPERS health plans.
Size: 2.14 mb
Hits: 320
Date modified: 08 - 22 - 2019

FSA and DCA Direct Deposit Form

Size: 115.79 kb
Hits: 301
Date modified: 09 - 05 - 2018

457 Enrollment Form

Use this form to enroll in the 457 plan for supplemental retirement.
Size: 860.63 kb
Hits: 264
Date modified: 10 - 02 - 2019

Cash-In-Lieu Form

This participation election from allows you to take cash in lieu of medical, dental, or vision insurance.
Size: 219.34 kb
Hits: 244
Date modified: 08 - 21 - 2019

457 Beneficiary Form

Use this form to designate beneficiaries for your 457 supplemental income plan.
Size: 123.47 kb
Hits: 235
Date modified: 10 - 02 - 2019

457 Change Form

Use this form to change your contribution rate if you already have a 457 supplemental retirement plan.
Size: 50.70 kb
Hits: 231
Date modified: 10 - 02 - 2019

403b - Plan Information and Enrollment Form

Download the information packet to learn more about the 403b supplemental retirement plan.
Size: 498.40 kb
Hits: 159
Date modified: 08 - 22 - 2019

HBD-12 Change Medical Insurance Effective 2020

Size: 193.76 kb
Hits: 150
Date modified: 09 - 19 - 2019

FSA and DCA Participation Election Form

Size: 308.35 kb
Hits: 143
Date modified: 12 - 18 - 2019

Disclaimer of Warranties/Accuracy of Information

The information contained on this webpage is provided for informational purposes only, and should not be construed as legal advice regarding any final benefit determinations. The content of this webpage is intended to provide general information only and may not reflect current legal developments as they may apply to your individual benefits status.

 You should not act or refrain from acting on the basis of any content included on this webpage without first seeking final confirmation from your benefits provider.

 The Cal Poly Corporation assumes no responsibility for any use to which the information on this webpage may be put, or for any errors and hereby expressly disclaims any liability with respect to any actions taken or not taken based on any or all the contents of this webpage. This webpage and its contents are provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, the implied warranties of merchantability, fitness for a particular purpose, or non-infringement.