• Forms
    Use the forms on this page to make changes to your benefits.  Any incomplete forms will not be processed.  Be sure to provide all required documents and information.
     
    Active Employee Forms
    Retired Employee Forms
    For Use by Active Employees Only
    Use this form to enroll-in or make qualified changes to your benefits.
     
    Required Documents
    Copy of the County issued marriage certificate, if enrolling a spouse for the first time
     
    Copy of the County issued birth certificates, if enrolling children for the first time
     
    Proof of loss of coverage, if applicable
     

    For Use by Active Certificated and Classified Employees Only
    Use this form to designate or update your District-paid life insurance beneficiaries.
     
    Required Documents
    None
     

    For Use for COBRA Enrollment Only
    Use this form if you are eligible to enroll in a COBRA Continuation Coverage plan.
     
    Required Documents
    None
     

    For Use by Active Management Employees Only
    Use this form to designate or update your District-paid life insurance beneficiaries.
     
    Required Documents
    None
     

    For Use by Active Police Officers and Sergeants Only
    Use this form to designate or update your District-paid life insurance beneficiaries.
     
    Required Documents
    None
    For Use by Retired Employees Only
    Use this form to enroll in the Blue Shield 65 Plus plan.
     
    Required Documents
    Copy of Medicare card(s)
     

    For Use by Retired Employees Only
    Use this form to enroll in the Kaiser Senior Advantage HMO Plan.
     
    Required Documents
    Copy of Medicare card(s)
     

    For Use by Retired Employees Only
    Use this form to enroll in or make qualified changes to your retirement benefits.
     
    Required Documents
    Copy of the County issued marriage certificate, if enrolling a spoouse for the first time
     
    Copy of the County issued birth certificate(s), if enrolling children for the first time
     
    Copy of Medicare cards, if applicable
     
    Poof of loss of coverage, if applicable
     

    For Use by Retiring Employees Only
    If you qualify, use this form to enroll in your retirement benefits.  Find out if you qualify here.
     
    Required Documents
    Copy of the first page of you retirement application to CalPERS or CalSTRS.
     

    For Use for Self-Pay Enrollment Only
    Use this form to enroll in a self-pay plan after your retirement benefits expire.
     
    Required Documents
    Copy of Medicare card(s), if applicable

     

Last Modified on February 25, 2020