Forms

Fillable Vision Claim Reimbursement Form

Don't have access to a printer? Use this form to submit your vision claim reimbursements.

2019-2020 SJCSD Insurance Rates

Updated rates increased 11/15/2019

Mutual of Omaha Conversion Application

Use this form to convert your Mutual of Omaha Life Insurance policy.

Mutual of Omaha Portability Application

If you plan to port your Mutual of Omaha Life Insurance, use this form.

2020 Vision Claim Reimbursement Form

Use this form for vision claim reimbursements in 2020.

Retiree 2020 Plan Year Enrollment Form

This form is for retirees making enrollment changes in 2020.

Active Enrollment Form 2019-2020 – New Rates

Be sure to use this form for any 2019-2020 active enrollment changes.

2020 Open Enrollment – Working Spouse Affidavit

This form is used when you are adding a spouse to the medical plans.

Spousal Affidavit – Family Status Change

Do you have a spouse on SJCSD Medical Plan? Fill this form out to be compliant.