Forms

Retiree Special Open Enrollment – Spousal Affidavit

Use this form if you have a spouse on Retiree Medical for changes during the Retiree Special Open Enrollment.

Retiree Special Open Enrollment – 2025 Enrollment Form

Use this form for the Retiree Special Open Enrollment!

Added Benefit – Additional EAP Services through Voya!

As an added benefit for all employees through Voya, you can access their Employee Assistance Program (EAP) services at no additional cost to you!

2025 Retiree Enrollment Form

Use this form to make changes to your retiree benefits for 2025.

2025 – 2026 Active Enrollment Form

The Active Enrollment Form is used for any changes for employee enrollment.

2025-2026 Family Status Change Form

If you have a family status change, or qualifying event, use the forms to complete the enrollment.

PBA Vision Reimbursement Form

Use this form for your PBA Vision Reimbursements.

2025 Retiree Spousal Affidavit

If you cover a spouse on the SJCSD Medical Plans, please be sure to fill out the attached form.

Hospital Indemnity Form – Preferred Benefit Administrators

Use this form for your Hospital Indemnity Reimbursement.