CCSF Authorization Form

Welcome to City & County of San Francisco Docusign Tool

Use this tool to lookup data and then enter pertinent info for sending a docusign.

Enroll Aflac & Mass Mutual Products before entering info for the docusign to allow for payroll deduction.
Confirm that all info is correct for each fields to be uploaded to the docusign. Especially their individual DSW number!!
Submit the form and then inform the client to look for a docusign arriving in their email by the end of the day to sign and date.

Need help?

Call or text OSA if you are having issues with this form.

ENTER CONTACT BOT?

Information Needed For Deduction Authorization Docusign To Be Sent

First Name

Email (Personal Preferred)

Middle Initial

Email Re-entry

Last Name

Phone Number (Any format)

DSW Number (6 digits)

DEPT CODE

Plan Type (Accident/CI/Etc)

Biweekly Dedution Amount

Adjusted Biweekly Dedution Amount (+$3)

Coverage Amount

Biweekly Dedution Amount

Adjusted Biweekly Dedution Amount (+$3)

* Allow up to 5 hours to receive the docusign to the email listed above.

SAMPLE FORM

Thank you for using the One Solution Form. This portal is provided for Licensed Agents assisting City and County of San Francisco Employees as a secure means of facilitating communication related to your insurance coverage. Information submitted through this form is used solely for the purpose of assisting with policies and is not retained, shared, or used for any other purpose beyond this transaction.