Open Enrollment Information and Forms

 

 

Core Benefits

DEPENDENT CHANGES FOR CERTIFICATED

Non-management Certificated staff members can use this form  during open enrollment to make changes to an existing health, dental, or vision plan, or to add and remove dependents, spouse, domestic partners, etc. 

If adding dependents, please submit birth certificate(s). If adding a spouse or domestic partner please provide a marriage certificate or proof of domestic partnership, and most recent 1040.

CERTIFICATED PART-TIME EMPLOYEE DECLINATION OF COVERAGE FORM

These forms are for part-time Certificated employees (Less than .49 FTE) who are electing to cancel or reject core benefit coverage. 

DEPENDENT CHANGES FOR CLASSIFIED, CLASSIFIED MANAGEMENT, CLASSIFIED RETIREES

These forms are for Classified Employees/Classified Management/District Paid Classified Retirees who are adding or removing dependents or a spouse or registered domestic partner to your core benefit plan. 

If adding dependents, please submit birth certificate(s). If adding a spouse, please complete the attached spousal overlay forms and provide a marriage certificate or proof of domestic partnership, and most recent 1040.

CLASSIFIED EMPLOYEE PLAN ELECTION FORM

This form should be used if you are electing to change your benefit plan.

CLASSIFIED REJECTION OF MEDICAL COVERAGE FORM

These forms are for part-time employees (working less-than six hours) who are electing to cancel or reject core benefit coverage. 

SISC ENROLLMENT FORM

This form may be used to enroll in core benefits if you have not previously enrolled.

Supplemental Benefit Elections

American Fidelity - Appointment Scheduler

Click here to schedule an appointment with an American Fidelity advisor to enroll or change your elective benefits. These benefit options may include a 403b, Section 125 (flexible spending), Accident Insurance, Long-term and Short-term Disability coverage, etc.