Enrollment Forms

Printable Benefit Enrollment Forms:

NOTE: You will need to download the forms and use Adobe PDF reader in order to fill out the forms electronically.

MEDICAL  

• Health Benefits Plan Enrollment Form

CASH IN LIEU - WAIVE SUSD MEDICAL

• Medical Coverage Waiver & Cash In Lieu Form
• Declaration of Health Coverage Form

DENTAL AND VISION

• Dental and Vision Insurance Enrollment Form

PARENT-CHILD RELATIONSHIP AFFIDAVIT

• Parent-Child Relationship Affidavit

Completed benefit enrollment forms may be scanned and emailed to:  Benefits@stocktonusd.net

Eligible Dependents for SUSD Benefit Plans:

• Spouse

• Registered Domestic Partner - current domestic partner registered with the California Secretary of State's Office

• • Domestic Partners - the cost of benefits for an enrolled Domestic Partner and children of the partnership is considered imputed income by the IRS. Imputed income is taxable and would be included in the employee's gross income, subject to Federal tax withholding and payroll taxes.  

• Children - includes natural born, adopted, stepchildren and children of registered domestic partners

• Parent-Child Relationship - children under age 26 and for whom the employee has assumed parental status or duties

• Disabled Children - children age 26 or older that have a mental or physical condition that prevents them from supporting themselves