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Forms for Retirees

For more information, visit the Employee and Retiree Benefits section.

PVSD Forms with Spanish
Form Title: Companion Care Enrollment Form
Description: Companion Care Enrollment Form
Category: Health Benefits - Retirees
Department: Benefits and Workers' Comp
Form Number: Revision Date: 8/1/2006
Annual Audit: Yes Audience: Public
Form Title: Medicare Enrollment Notice
Description: Important notice to retirees - Medicare A & B mandatory enrollment.
Category: Health Benefits - Retirees
Department: Benefits and Workers' Comp
Form Number: Revision Date: 2/25/2009
Annual Audit: Yes Audience: Public
Form Title: New Retiree Health Benefits Election Form
Description: New Retiree Health Benefits Election Form
Category: Health Benefits - Retirees
Department: Benefits and Workers' Comp
Form Number: Revision Date: 2/12/2009
Annual Audit: Yes Audience: Public
Form Title: Open Enrollment Form: Retirees
Description: Open Enrollment Form: Retirees
Category: Health Benefits - Retirees
Department: Benefits and Workers' Comp
Form Number: Revision Date: 4/9/2009
Annual Audit: Yes Audience: Public
Form Title: Plans, Rates, and Providers for Retirees
Description: Monthly Rates for Under 65 and Over 65. Contribution Worksheet. Plan Providers.
Category: Health Benefits - Retirees
Department: Benefits and Workers' Comp
Form Number: Revision Date: 3/7/2011
Annual Audit: Yes Audience: Public
Form Title: Retiree Health Benefits Contributions - Certificated
Description: Retiree Health Benefits Contributions - Certificated
Category: Health Benefits - Retirees
Department: Benefits and Workers' Comp
Form Number: Revision Date: 2/9/2009
Annual Audit: Yes Audience: Public
Form Title: Retiree Health Benefits Contributions - Classified
Description: Retiree Health Benefits Contributions - Classified
Category: Health Benefits - Retirees
Department: Benefits and Workers' Comp
Form Number: Revision Date: 2/9/2009
Annual Audit: Yes Audience: Public
Form Title: Retiree Health Benefits Information
Description: Retiree Health Benefits Information
Category: Health Benefits - Retirees
Department: Benefits and Workers' Comp
Form Number: Revision Date: 3/7/2011
Annual Audit: Yes Audience: Public
Form Title: STRS and Medicare Eligibility and Premiums
Description: STRS and Medicare Eligibility and Premiums
Category: Health Benefits - Retirees
Department: Benefits and Workers' Comp
Form Number: Revision Date: 12/5/2004
Annual Audit: Yes Audience: Public