Forms

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.

Short-Term Disability Calculator

This worksheet helps you figure out the cost of disability insurance.

Florida Blue – Out-of-State Medical Claim Form

Use this form to file medical claims that occur out-of-state.