Forms

General Forms

• Enrollment Card
  
• Beneficiary Designation Form
  
• Address Change Form
  

Medical Forms

• Pacificare Enrollment Form
  
• Pacificare Secure Horizons Enrollment Form
  
• Pacificare Change Form
  
• HealthNet Enrollment Form
  
• HealthNet Medicare Part D Enrollment Form
  
• Kaiser Enrollment Forms (Non-Medicare Eligibles):  English     Spanish
  
• Kaiser Enrollment Form (Medicare Eligibles) - English only
  
• Self-Funded Medical Claim Form
• Prescription Claim Form
• Dental Claim Form
  

Pension Forms

GENERAL FORMS

• Plan Booklet (Parts A & B)
• Request for Pension
• Qualified Domestic Relations Order (Information & Sample)
• Electronic Funds Transfer Form (Parts A & B)
• Pre-Retirement Death Benefits
• Application for Coverage as A Retiree for Health & Welfare Benefits
• Federal Pension Withholding Form
• California Pension Withholding Form
  

PART A DOCUMENTS

• Disability Application Form
• Request for Pension