Benefit Enrollment Forms

Health Enrollment Form

Vision Enrollment Form

Dental Enrollment Form


Medical Waiver of Coverage

Employees who are eligible for health benefits (0.50 FTE or greater) and choose not to enroll in a medical plan must complete and submit a Medical Waiver of Coverage Form.

The waiver form is required to document your decision to decline medical coverage.

Medical Waiver of Coverage

Important: Submitting a benefit enrollment form does not automatically enroll you in a benefit plan.

To complete your enrollment, you must:

  1. Submit all required benefit enrollment forms.
  2. Provide all required supporting documentation, such as:
    • Social Security cards
    • Birth certificates
    • Marriage certificates/licenses
    • Domestic partner documentation (if applicable)
    • Any other eligibility documentation requested by Fiscal Services
  3. Receive confirmation from Fiscal Services that your enrollment has been reviewed and processed.

Health Benefit Cost Worksheets

Estimate Your Benefit Costs Before Enrolling

New employees are strongly encouraged to use the Health Benefit Cost Worksheets before selecting benefits. These interactive DJUSD Health Benefit Cost Worksheets allow employees to compare health plan options and estimate their monthly payroll deductions based on:

-Health plan selection
-Coverage tier
-Bargaining unit
-FTE
-Work calendar (10, 10.5, 11, or 12 month) Employees that work 10.5 work calendar, please select 11 month pay cycle from drop down in forms as there are 11 pay periods.
-Effective Date & Coverage Period

Because District contribution caps, blended rates, and employee payroll deductions vary by employee group, separate worksheets are available for:

Certificated: Health Benefits Cost Worksheet

 Classified: Health Benefits Cost Worksheet
 ALT/Confidential: Health Benefits Cost Worksheet

Employees should use the worksheet that corresponds to their employee group to obtain the most accurate estimate of their benefit costs.

For a step-by-step tutorial on how to use the cost worksheets, please watch the short, informative videos below:

How to use Health Benefits Cost Worksheet- Certificated

How to use Health Benefits Cost Worksheet - Classified


The cost worksheets do not replace the InformedK12 benefits enrollment form; this is to estimate cost and give employees ease in pricing out various plans or enrollment scenarios. All employees must complete the InformedK12 enrollment forms linked at the top of this page to enroll in benefits.

InformedK12 Notifications

  • Once you complete and submit your forms through InformedK12, you will receive a confirmation email at the email address used when the form was initiated.
  • If your form is returned for corrections or additional information, InformedK12 will send a notification to the same email address with instructions on the required updates.
  • Please monitor your email and respond promptly to any requests for corrections or missing documentation to avoid delays in processing your benefits.

Your benefit enrollment is not complete, and coverage is not effective, until all required forms and supporting documentation have been submitted, reviewed, and approved by Fiscal Services.

If you do not receive confirmation that your enrollment has been processed, please contact Fiscal Services to verify your enrollment status.

This version clearly distinguishes between an InformedK12 submission confirmation and the Fiscal Services enrollment approval, which helps prevent employees from assuming that submitting a form means they are enrolled.