eBenefits Self-service Electronic Signature Authorization Form

Complete and return this form to the Campus Benefits Office. The Oracle/Peoplesoft eBenefits Self­Service module enables you to electronically submit your benefits transaction(s) request(s) to the campus Benefits Office. The State Controller’s Office (SCO), as the pay agent for California State University (CSU), makes, cancels and/or changes a deduction or reduction at the request of the employee authorized to have the deduction or reduction. In order for the SCO to process benefits enrollments, changes and deductions that are submitted electronically to the campus Benefits Office, the CSU is required to maintain a handwritten authorization, signed by the individual from whose salary or wages the deduction is to be made. By signing this document, I _____________________________________ (print full name) authorize the campus Benefits Office to accept via electronic submission, my self­service benefits transactions requests that I am eligible for, which may include: ­ New Hire Enrollment(s) and annual Open Enrollment(s): health, dental, vision, flexible spending plans (Health and/or Dependent Care Reimbursement Account Plans (HCRA/DCRA)); ­ Savings Plan Enrollment(s) and Change(s): (CSU 403(b) Tax Sheltered Annuity (TSA) Program); ­ Life Event Processing (i.e., change in status events); and ­ Dependent Information By signing this authorization request, I agree to submit any supporting documents required by the Benefits Office in order to process benefits transaction(s) request(s) on my behalf. I also authorize the Benefits Office to send necessary information to the SCO and my selected providers to initiate and support benefits deductions and/or enrollment. My signature on this form certifies that: I agree that my user ID and password constitute my electronic signature and I understand that any information submitted using eBenefits Self­Service is electronically certifying my signature. I understand that I am legally bound, obligated, or responsible by use of my electronic signature as much as I would be by my handwritten signature. I agree that I will protect my electronic signature from unauthorized use, and that I will contact the CSU immediately upon discovery, if I suspect that my electronic signature has been lost, stolen, or otherwise compromised. I certify that my electronic signature is for my own use, that I will keep it confidential, and that I will not delegate or share it with any other individual. This request is effective immediately upon receipt by the campus Benefits Office, and will remain in effect until I choose to cancel it, via written notification. Employee Signature Date Signed Accepted by Authorized Campus Representative Date Signed
CSU Office of the Chancellor/ Human Resources Administration Effective September 17, 2007