Benefits Forms

When submitting applications for Enrollment please follow the  guidelines below:

Medical Application

This SDP Health Application is for all SDP provided medical and health plans. You may need to contact your union for prescription, dental and vision benefits.
Complete all sections in entirety.

Please refer to General Documentation Required section for a list of documents that may need to accompany your completed application. The completed application and documentation, if required, can be faxed in to the Benefits Office at (215) 400-4631 or emailed to benefits@philasd.org. Please call (215) 400-4630 to confirm receipt.

Vision

Prescription Drugs –  CASA, SPAP and Non-Represented Employees ONLY:

 

Injectable Prescription Drugs –  PFT and Local 634 employees. Select the form corresponding to your prescription. If your prescription is not listed, use the General Direct Ship Request form. 

Life Insurance Beneficiary Forms

Flu Vaccine Reimbursement Form

Flu Vaccination Reimbursement FormFlu Vaccination Reimbursement Form

Flexible Spending Account (FSA)

Ameriflex Substantiation Form

FLEX-Correction form

For all types of accounts ** To be sent directly to AmeriFlex

Commuter or Parking Accounts

403(b) & 457(b)

Wage Continuation (Salary Continuance)

PFT, CASA, Non-Represented, Local 634, District 1201/32 BJ and SPAP employees can only apply for Wage Continuation coverage within 30 days of date of hire or during the annual Open Enrollment period in May. Wage Continuation enrollment and cancellation forms are available May 1 to May 31 on the Open Enrollment page.

Name Change/Demographic Change Request

Employees must contact Payroll, payrollhelp@philasd.org or 215-400-4490 to request an address change or a change in tax withholding status.

COBRA /RETIREE Coverage forms

An Automatic Payment (Ach) Request