Human Resources

Please use the information below to access forms or websites that you may need to learn about your benefits and make changes if needed.  If you have questions, please contact us by using the contact form at the bottom of the page.

Forms and Resources

Blue Cross Application: Use this form to make changes to your Blue Cross Health Insurance Plan

CHIP Notice: Federal form regarding potential state assistance with healthcare premiums  Spanish CHIPRA

Direct Deposit: Use this form to authorize payroll payments directly to your bank accounts

Education Foundation Deduction: Use this form to donate part of your paycheck to the Jefferson Education Foundation

EOBs for Buy Down: Information for submitting Explanation of Benefits forms for the Buy Down Program

Flex Reimbursement: Use this form if you have a Section 125 Flex account

Glossary of Health Coverage and Medical Terms

Healthcare Exchange Notice: Federal form notice regarding the district’s health plan

Healthy Measures Application: Use this form to apply to participate in the Healthy Measures Buy Down Program

Life Map Beneficiary: Use this form to change those designated as beneficiaries for Life Map insurance.

Group Health Plan Notices and Medicare D Notice for Plan Participants: English Participant

Payroll Deduction Authorization: Use this form to make changes to an authorized payroll deduction

PERSI 401k: Use this form for PERSI Choice 401k Plan changes

PERSI Beneficiary: Use this form to change those designated as beneficiaries for PERSI

W-4 Changes: Login to iVisions to change your number of deductions on your W-4

For additional questions you may contact the Human Resources and Payroll Department using the form below.

Contact Human Resources

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