Benefits Forms

When submitting applications for Enrollment please follow the  guidelines below:

Medical Application

This SDP Health Application and Attestation Form 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. Visit the Independence Blue Cross site for up to date information on all Independence Blue Cross plans.

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 if submitting by fax.

Vision

Dental –  CASA, SPAP and Non-Represented Employees ONLY

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

Self- Injectable Prescription Drugs for PFT employees. Select the form corresponding to your prescription. If your prescription is not listed, use the General Direct Ship Request form. More information is available on the Self-Injectables page

Life Insurance Beneficiary Forms

Flexible Spending Account changes 

No forms to complete! for changes contact the Employee Benefits Center at 1-800-307-0230 between 8:30AM – 5:30PM EST Monday through Friday for all questions.

Flu Vaccine Reimbursement Form

Flu Reimbursement Form from Independence

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.  Forms are only available May 1 through May 31.

Wage Continuation Enrollment Form

Wage Continuation Cancellation Form

First year PFT employees can contact benefits@philasd.org for enrollment in their first year.

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

How do I change or correct my name on my Social Security number card?

If you legally change your name because of marriage, divorce, court order or any other reason, you must tell Social Security so you can get a corrected card. You cannot apply for a card online. There is no charge for a Social Security card. To get a corrected Social Security card, you will need to:

For complete instructions, please go to  Social Security Number and Card.
For more information, read the pamphlet, Your Social Security Number and Card.