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Resource Page for Employees

FORMS

CERTIFICATED & MANAGEMENT Health Insurance-Related Forms (SISC)

ENROLLMENT FORMS:

 

OTHER FORMS/NOTICES:

Changes to your personal information should be made using the Membership Change Form. 

these changes include:

  • Address change
     
  • Add/remove family members (documentation required: copy of hospital birth announcement to add children(must bring in county recorded birth certificate when it is received); copy of certified marriage license/certificate of registered domestic partnership to add spouse/registered domestic partner; and copy of final divorce decree to remove ex-spouse)
     
  • Make corrections to your information at SISC, Anthem, Kaiser, Delta and/or VSP

Instructions: Complete the  Membership Change Form and bring to Risk Management, along with copies of birth certificate, certified marriage license, divorce decree, etc., as appropriate. 

IMPORTANT:  Employees have 30 days from the event date to add a newborn, adopted child or new spouse/ registered domestic partner, as well as to remove an ex-spouse/ registered domestic partner.


SISC Privacy Notice/Opt Out Form

Life Insurance Forms

Group Term Life Insurance Beneficiary Form - use this form to select/change the beneficiary for your District-sponsored group, term life insurance policy.

American Fidelity Forms

Classified Health Insurance-Related Forms (CVT/FBC)

MEDICAL ENROLLMENT FORMS:

  • CVT ENROLLMENT FORM - Fill out for ALL CVT medical plans
  • KAISER ENROLLMENT - Fill out in addition to CVT enrollment form if you are enrolling in Kaiser
  • HMO ENROLLMENT FORM - Fill out in addition to CVT enrollment form if you are enrolling in Anthem HMO
  • Classified Opt-Out Form - You can only opt-out if you are grandfathered, you work less than 8 hours per day, or you are enrolled in Medicare. (Proof of enrollment required within 30 days of qualifying event.)

MEDICAL CHANGE FORM:

Changes to your personal information should be made using the change form. These changes include:

  • Address change
  • Add/remove family members (documentation required: copy of hospital birth announcement to add children(must bring in county recorded birth certificate when it is received); copy of certified marriage license/certificate of registered domestic partnership to add spouse/registered domestic partner; and copy of final divorce decree to remove ex-spouse)
  • Make corrections to your information at CVT, Anthem or Kaiser

Instructions: Complete the  Membership Change Form and bring to Risk Management, along with copies of county recorded birth certificate, certified marriage license, divorce decree, etc., as appropriate. 
IMPORTANT:  Employees have 30 days from the event date to add a newborn, adopted child or new spouse/ registered domestic partner, as well as to remove an ex-spouse/ registered domestic partner.

 

DENTAL/VISION ENROLLMENT & CHANGE FORMS:

 

 

 

RETIREE HEALTH INSURANCE FORMS

Use these forms to notify the District you are retiring from the District, and wish to convert your health insurance.

 

Kaiser Senior Advantage Form

 

NEW RETIREE SELECTION FORMS

2017/2018 RETIREE OPEN ENROLLMENT SELECTION FORMS