Benefits Forms

When submitting applications for Enrollment please follow the  guidelines below:

Medical Application

This SDP-Health-Application and Attestation 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

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.

Name Change/Demographic Change Request

  • Demographic-Change-Request. Use this form to updae name, gender or pre-fix or correct date of birth.
  • Marital Status Change Request. Use this form to update your voluntary marital status, not your tax filing status. Contact the Payroll Department, payrollhelp@philasd.org for tax filing status.

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