Forms

2023 PBA Vision Reimbursement Form

Use this form in 2023 for your PBA Vision Reimbursements.

2023 SJCSD Retiree Enrollment Form

Use the Retiree Enrollment form to make changes to your current insurance, or update your beneficiary or address.

2023 Retiree Spousal Affidavit

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

Family Status Change Form 2022-2023

If you have a family status change, use this form to complete the change with the HR Benefits Department.

Spousal Surcharge Affidavit Form 2022-2023 – Open Enrollment

If you are planning on adding a spouse during Open Enrollment to the SJCSD Self-Funded Medical Plans, please fill out this form to determine if the Spousal Surcharge will impact you.

Hospital Indemnity Form – Preferred Benefit Administrators

Use this form for your Hospital Indemnity Reimbursement.

Vision Claim Form – Preferred Benefit Administrators

Need to file a vision claim? Use this form to file directly with Preferred Benefit Administrators (PBA).

Voya Additional Term Life Insurance Enrollment Form

If you want to enroll in Voya Additional Term Life Insurance, use this form.

Flexible Spending Account Enrollment Form

Use this form when enrolling in Flexible Spending Accounts.