ACSIG : Alameda County Schools Insurance Group

Please fill out the form and save to your desktop. Print out and email to Amber White at awhite@acsig.com or Fax to 925-225-0653.

Vison & Dental	Workers' Comp	COBRA
Delta Non-Voluntary	Keenan.com (all forms are available on Keenan's website	COBRA Model General - A
EDGE Delta Dental Plan		COBRA Model General - B
Delta Dental Enrollment Application		COBRA Continuation Coverage Rights
Billing Change Request		COBRA HealthNet Enrollment Application Form
		Blue Cross COBRA
		PacificCare COBRA
		CalPERS Benefits Plan Enrollment Form
		ACSIG Notice / Election
		Kaiser COBRA Form
		VSP Membership Update Form

Customer Service Telephone Numbers:

Kaiser Permanente	800.464.4000
HealthNet	800-638-3889
PacifiCare	800-624-8822
Blue Cross	800-227-3771
Vision	800-877-7195
Delta Care USA & Delta Vision	800-422-4234
Delta Dental Customer Service Fax:	800-335-8227
Delta Dental Customer Service	888-335-8227