Retiree Forms

General Forms for Retirees

• CalPERS Affidavit of Parent-Child Relationship

• Application for Retiree Health Benefits 

• 2014 Enrollment/Change form for Retirees and Survivors

• 2018 Enrollment/Change form for Retirees and Survivors  (Dental & Vision only)

• CalPERS Health Plan Enrollment/Change Form  

Please complete only the highlighted portions of the form. To add a new dependent, please put an "A" in the Action Code column (highlighted on the form) to the left of the new dependent's name.

To delete a dependent from your medical plan, put a "D" in the Action Code column to the left of the name of the dependent you wish to delete from your plan. 

• SafeGuard - Health Plans Change Form  

• Kaiser Senior Advantage Application

• Blue Shield - Request for Continuity of Care

• Blue Shield - Declaration of Disability for Overage Dependent Child

• Blue Shield - International Claims Form

• Blue Shield - Rx Claim Form

• Blue Shield - Statement of Claim Form

• Blue Shield - Disabled Dependent Form

• Kaiser - Claim for Emergency Services Form

• VSP Out of Network Reimbursement Form

Domestic Partner Forms and Brochure

•  Affidavit of Domestic Partnership

•  Application for Domestic Partner Health Benefits

• Tax Form

• Terminating a California Registered Domestic Partnership

• Declaration of Termination of Domestic Partnership