• Benefits Forms
    Use the forms on this page to make qualified changes to your health benefits.  Any incomplete forms cannot be processed.  Please be sure to provide all required documents and information.
  • Active Employee Forms
    For use by Active SAUSD Employees Only
     
    Use this form to enroll in or make qualified changes to your health benefits.
     
    Required Documents
    A copy of the County issued marriage certificate if enrolling a spouse for the first time.

    A copy of the County issued birth certificate if enrolling a child for the first time.

    Proof of loss of coverage if applicable.


    For use by Active SAUSD Employees Only
     
    Use this form to designate or update your district-paid life insurance beneficiaries.
     
    Required Documents
    None
  • Post-Employment Forms
    For use for COBRA Enrollment only
     
    Use this form if you are eligible to enroll in COBRA Continuation Coverage.
     
    Required Documents
    None
  • Retired Employee Forms
    For use by SAUSD Retirees Only
     
    Use this form to enroll in the Blue Shield 65 Plus HMO plan.
     
    Required Documents

    A copy of the Medicare card for the individual enrolling.


    For use by SAUSD Retirees Only
     
    Use this form to enroll in the Kaiser Senior Advantage HMO plan.
     
    Required Documents

    A copy of the Medicare card for the individual enrolling.


    For use by SAUSD Retirees Only
     
    Use this form to enroll in or make qualified changes to your retirement benefits.
     
    Required Documents
    A copy of the County issued marriage certificate if enrolling a spouse for the first time.

    A copy of the County issued birth ceritificate if enrolling a child for the first time.

    A copy of a Medicare card if applicable.

    Proof 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
    Verification of your retirement through CalPERS/CalSTRS
    (A copy of the first page of the application marked received by PERS/STRS or the award letter is accepted)
  • Post-Retirement Benefits Forms
    For use for Self-Pay Enrollment Only
     
    If you are eligible, use this form to enroll in a self-pay plan through SAUSD.
     
    Required Documents
    A copy of a Medicare card if applicable.
Last Modified on July 7, 2022