Open Enrollment

Dependent Changes for Certificated Employees & Certificated Retirees

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.

SISC Change Form

Dependent Changes for Classified Employees, Classified Management, & Classified Retirees

Use this form to add or remove dependents, a spouse, or registered domestic partner to your core benefit plan.

SISC Change Form

Spousal Overlay Form

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.

Please contact your Benefit Technician for more information and for the appropriate form.

Classified Employee Plan Election Form

(6 or more hours)

This form is for employees working more than six hours and should be used if you are electing or changing your benefit plan.

Plan Election Form

Part-Time Classified Employee Plan Election Form

(Less than 6 Hours)

These forms are for employees working between three and six hours and should be used if you are electing or changing your benefit plan.

Part-time Election Form

SISC Enrollment Form

Spousal Overlay Form

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.

Coverage Rejection Form

Supplemental Medical Plan for Retirees

Retirees over age 65 and currently on our health plan, have the option enroll in Companion Care as a medical supplement. Please note that there is a 45-day waiting period for this plan.

Benefits Summary

Application Form