|
|
- ABP
= Alternate Benefits Program
- ACTS
= Additional Contributions Tax-Sheltered
- ALL Plans
= Universal Forms
- DCOMP
= NJ State Employees Deferred Compensation Plan
- DCRP = Defined Contribution Retirement Program
- Financial
= Financial Reporting
- JRS
= Judicial Retirement System
- PERS
= Public Employees' Retirement System
- PFRS
= Police & Firemen's Retirement System
- SACT
= Supplemental Annuity Collective Trust
- SHBP/SEHBP
= State Health Benefits Program/School Employees' Health Benefits Program
- SPRS
= State Policemen's Retirement System
- TPAF
= Teachers' Pension & Annuity Fund
Click on a form to see a version
ready for download. |
|
ABP = Alternate Benefits Program
Please
note that many State colleges and universities
and county colleges of New Jersey use their own
internally-developed forms for the ABP. |
|
Fund |
Description |
ABP |
ABP/DCRP Designation of Beneficiary Form |
|
ABP
|
Carrier
Election and Allocation Form |
|
ABP |
Choosing
between the PERS and ABP |
|
ABP
|
Election
of Retirement Coverage - Transfer from PERS/TPAF |
|
ABP
|
Enrollment
Application |
ABP |
Enrollment/Transfer Application
(For transfers from PERS or TPAF) |
|
ABP
|
Frequently
Asked Questions |
|
ABP
|
Leave
Of Absence (LOA) Form |
|
ABP
|
Retirement
Application |
|
ABP |
Request
for PERS and ABP Retirement Income Illustrations |
|
ABP
|
Salary
Reduction Agreement |
|
ABP
|
Transfer
Form |
|
ABP |
Alternate
Benefit Program Member Handbook |
ABP |
ABP Long-Term Disability Form |
ACTS
= Additional Contributions Tax-Sheltered Program
Please
note that many State colleges and universities
and county colleges of New Jersey use their own
internally-developed forms for the ACTS Program. |
|
ACTS
|
ACTS
to SACT Transfer Form |
|
ACTS
|
Carrier
Election Form |
|
ACTS
|
Salary
Reduction Agreement |
ALL
= All Plans |
|
ALL
|
Affidavit
of Name Change |
ALL |
Application for Dependent Death Benefits |
|
ALL |
Application
for Volunteer Emergency-Worker's Survivors Pension (VESP) |
|
ALL
|
Authorization
for Direct Deposit of Benefit Payment (Electronic Fund Transfer
Form for Members Who Are Retired) |
ALL |
Automated Information System Update - Flier |
|
ALL
|
Benefits
When Terminating Employment |
|
ALL
|
Retiree Beneficiary
Designation Form |
ALL |
Certified Loan Request |
|
ALL
|
Change
of Address Form |
|
ALL
|
Death
Claims: Accidental Death Application |
|
ALL
|
Death
Claims: Accidental Death - Employer Certification |
|
ALL
|
Death
Claims: Active Beneficiary Verification Form/ Alliance Account |
|
ALL
|
Death
Claims: Active Beneficiary Verification Form/ under $5,000 |
|
ALL
|
Death
Claims: Alliance Account Information Sheet |
|
ALL
|
Death
Claims: Beneficiary Services Estate Federal Tax Withholding Certificate |
|
ALL |
Death
Claims: Certification of Service & Final Salary (P-29) |
|
ALL
|
Death
Claims: Last Check Benefit Form |
ALL |
Death
Claims: Beneficiary Services Option 1 Reserve Certificate of Claimant |
|
ALL
|
Death
Claims: Non-member Designation of Beneficiary |
|
ALL
|
Death
Claims: Retired Beneficiary Verification Form/ Alliance Account |
|
ALL
|
Death
Claims: Retired Beneficiary Verification Form/ under $5,000 |
|
ALL
|
Death
Claims: Beneficiary Services Non-spouse Rollover Election Form |
ALL |
Death
Claims: Beneficiary Services Spouse Rollover Election Form |
|
ALL
|
Direct
Rollover/Trustee-to-Trustee Transfer of Funds for the Purchase
of Additional Service Credit (PERS, TPAF, PFRS, SPRS) |
|
ALL
|
Directions
TO Division of Pensions & Benefits |
|
ALL
|
Directions
FROM Division of Pensions & Benefits |
|
ALL |
Employee
Tax Certification - Domestic Partner/Civil Union Partner Benefit |
ALL |
EPIC User's Information Guide |
ALL |
HIPAA:
Member Authorization Form for Use and Disclosure of Protected and Private Information (Member Authorization Form) |
|
ALL
|
Interfund
Transfer Form |
|
ALL |
IROC
(Internet Based Report of Contributions) Users' Guide |
|
ALL
|
Purchase:
Employer Verification Form |
|
ALL
|
Report
of Transfer |
ALL |
Tier to Tier Transfer Form |
|
ALL
|
Request
for Publications |
|
ALL
|
Request
for USERRA Eligible Service |
ALL |
Retiree Tax Certification - Domestic Partner Benefit |
|
ALL |
Retirements:
Change Retirement Application |
|
ALL
|
Retirements
(Disability): Medical Examination by Treating Physician Form |
|
ALL
|
Retirements
(Disability): Authorization to Release Medical Records |
|
ALL
|
Retirements
(Disability): Employer Certification of Disability Retirement |
|
ALL
|
Retirements: Waiver or Restoration of Pension Allowance |
|
ALL
|
Supplemental
Biweekly Certification |
|
ALL
|
Terminate
Electronic Funds Transfer ( EFT) Form |
ALL |
Withdrawal: Employer's Certification for Withdrawal |
DCOMP
= NJ State Employees Deferred Compensation Plan
Only employees of the State
of New Jersey may participate in the NJ
State Employees Deferred Compensation Plan. |
|
DCOMP |
Catch-Up
Form |
|
DCOMP |
Enrollment
Packet |
|
DCOMP
|
Enrollment
Request |
|
DCOMP |
Salary
Deferral Change Form (Prudential) |
DCRP = Defined Contribution Retirement Program |
DCRP |
ABP/DCRP Designation of Beneficiary Form |
DCRP |
NJ DCRP Enrollment Application |
DCRP |
NJ DCRP Waiver of Retirement Program Participation for Employees Enrolled in the PERS or TPAF (for PERS and TPAF Members Earning Salary in Excess of the Social Security Maximum) |
DCRP |
|
DCRP |
Election to Participate in the DCRP for PERS or TPAF Employees Who Previously Waived DCRP Enrollment |
DCRP |
NJ DCRP Application for Transfer/Rehire (Intra-fund) |
DCRP |
NJ DCRP Eligibility Status Change Verification Form |
DCRP |
NJ DCRP Transmittal of Local Government Ordinance or Resolution |
DCRP |
Employee/Independent Contractor Checklist |
Financial = Pensions Financial Document |
|
Financial
|
Completing
the Report of Contributions |
|
Financial
|
Delinquent
Notice |
Financial |
Employee Tax Certification - Domestic Partner Benefit |
Financial |
Retiree Tax Certification - Domestic Partner Benefit |
|
Financial
|
Report
of Temporary Disability Insurance |
|
Financial
|
Report
of Unemployment Insurance, etc. |
|
Financial
|
Sample
Payroll Certification of Payroll Deductions |
|
Financial
|
Sample
Report Of Contributions |
|
Financial
|
Sample
Salary Sheet |
|
Financial |
TEPS
Application |
|
Financial
|
TEPS
Application (Fill in
and Print, Acrobat 4.0 or Higher Needed) |
|
Financial
|
TEPS
Procedure Guide |
|
Financial
|
TEPS
Shortage Transmittal Instructions |
JRS
= Judicial Retirement System |
JRS |
Enrollment Application |
|
JRS
|
Loan
Application |
|
JRS
|
Retirement
Application |
|
JRS |
JRS
Contributory Group Life Insurance Information Sheet |
PERS
= Public Employees Retirement System |
|
PERS/ABP |
Choosing
between the PERS and ABP |
|
PERS
|
Enrollment
Application |
|
PERS
|
GLI: Application to Waive GLI in Excess of $50,000 |
|
PERS
|
GLI:
Application to Reinstate GLI in Excess of $50,000 |
|
PERS
|
GLI:
Contributory Life Insurance: Withdrawal Form |
|
PERS
|
GLI:
Personal Life Insurance Premium Remittance Form |
|
PERS
|
LEO
Eligibility Information |
|
PERS
|
LEO
Waiver Form |
PERS |
Non-Veteran Elected Officials Roster |
PERS |
PERS Optional Enrollment Waiver (For Non-Veteran Elected Officials) |
PERS |
Purchase:
Employer Verification of Leave of Absence for Union Representation |
PERS |
Purchase:
Authorization to Purchase Service Credit — Union Representation |
|
PERS
|
Report
of Transfer/Multiple Enrollment |
|
PERS |
Report
of Transfer/Multiple Enrollment (
Fill in and Print, Acrobat 4.0 or Higher Needed) |
|
PERS
|
Retirement:
Certification of Service and Final Salary |
PERS |
Retirement: Change of Retirement (Date, Type, Option) |
PERS |
Retirement: Authorization for Direct Deposit of Benefit Payment |
|
PERS
|
Retirement:
Retirement Estimate Request |
|
PERS
|
Retirement:
Retirement Estimate Request
(Fill in and Print, Acrobat 4.0
or Higher Needed) |
PERS |
Employee/Independent Contractor Checklist |
| PERS: Prosecutors Part
Only |
PERS
- Prosecutors Part Change of Position Form (for County
Prosecutors) |
| PERS: Prosecutors Part
Only |
PERS
- Prosecutors Part Change of Position Form (for State
Prosecutors) |
| PERS: Prosecutors Part
Only |
PERS
- Prosecutors Part Change Form - Government Employee Interchange Act |
| PERS: Prosecutors Part
Only |
PERS
- Prosecutors Part Request for Retirement Estimate |
PFRS
= Police and Firemen's Retirement System |
|
PFRS
|
Enrollment
Application |
|
PFRS |
Planning
for Retirement Booklet |
|
PFRS |
Report
of Examining Physician |
PFRS |
Resolution: County Fire Marshals and Assistant County Fire Marshals to Perform Fire Supression Duties |
|
PFRS
|
Retirement:
Certification of Service & Final Salary |
|
PFRS |
Retirement:
Retirement Estimate Request |
|
PFRS
|
Retirement: Retirement
Estimate Request
(Fill in and Print, Acrobat 4.0
or Higher Needed) |
PFRS |
Retirement:
Change of Retirement (Date, Type) |
|
PFRS
|
Report
of Transfer |
|
PFRS |
Report
of Transfer (Fill in
and Print, Acrobat 4.0 or Higher Needed) |
|
PFRS
|
Table:
Retirement and Death Benefits |
SACT
= Supplemental Annuity Collective Trust |
|
SACT
|
Personal Contribution Form |
SACT |
Application for Settlement at Retirement |
SACT |
Distribution
Form (For Lump Sump Option Only) |
|
SACT
|
Beneficiary
Designation Form |
|
SACT
|
Change
Contribution Rate Request |
|
SACT
|
Enrollment
Request |
|
SACT
|
Information
Booklet |
SACT |
SACT Loan Payoff Form |
|
SACT
|
Salary
Reduction Agreement |
|
SACT
|
Withdrawal
Application |
SHBP
= State Health Benefits Program
SEHBP
= School Employees' Health Benefits Program |
SHBP/SEHBP |
Active
Employee Dental Benefits Application (State and Local Version) |
SHBP/SEHBP |
Active State
Employee Health Benefits Application |
| SHBP/SEHBP |
High Deductible Health Plan (HDHP) Active State Employee Health Benefits Application |
| SHBP/SEHBP |
Health Savings Account (HSA) form for High Deductible Health Plans (HDHP) - form for State employees paid through Centralized Payroll |
SHBP/SEHBP |
Active Local Government
Employee Health Benefits Application |
| SHBP/SEHBP |
High Deductible Health Plan (HDHP) Active Local Government Employee Health Benefits Application |
| SHBP/SEHBP |
Health Savings Account (HSA) form for High Deductible Health Plans (HDHP) |
SHBP/SEHBP |
Active Education Employee Health Benefits Application |
| SHBP/SEHBP |
High Deductible Health Plan (HDHP) Active Education Employee Health Benefits Application |
SHBP/SEHBP |
State
Part-time Active Employee Health Benefits Application |
| SHBP/SEHBP |
High Deductible Health Plan (HDHP) State
Part-time Active Employee Health Benefits Application |
SHBP/SEHBP |
Chapter 375 Application for Coverage of Child until Age 31 |
SHBP/SEHBP |
State
Intermittent Employee Health Benefits Application |
| SHBP/SEHBP |
High Deductible Health Plan (HDHP) State
Intermittent Employee Health Benefits Application |
SHBP/SEHBP |
NJ National Guard — New Jersey SHBP Application |
SHBP/SEHBP |
Affidavit
of Dependency |
SHBP/SEHBP |
COBRA:
Assistance Eligibility Request Form |
SHBP/SEHBP |
COBRA:
Assistance Eligibility Waiver Form |
SHBP/SEHBP |
COBRA Rates |
SHBP/SEHBP |
COBRA:
Full-time State and Local COBRA Application |
| SHBP/SEHBP |
COBRA: High Deductible Health Plan (HDHP)
Full-time State and Local COBRA Application |
SHBP/SEHBP |
COBRA:
Full-time State and Local COBRA Application (Fill
in and Print Employer Portion, Acrobat 4.0 or Higher Needed) |
| SHBP/SEHBP |
COBRA: High Deductible Health Plan (HDHP)
Full-time State and Local COBRA Application (Fill
in and Print Employer Portion, Acrobat 4.0 or Higher Needed) |
SHBP/SEHBP |
COBRA:
Part-time Employee COBRA Application (for
part-time employees of the State of NJ and part-time faculty
members employed at New Jersey public institutions of higher
education) |
| SHBP/SEHBP |
COBRA:
High Deductible Health Plan (HDHP) Part-time Employee COBRA Application (for
part-time employees of the State of NJ and part-time faculty
members employed at New Jersey public institutions of higher
education) |
SHBP/SEHBP |
COBRA: Part-time Employee COBRA Application (for
part-time employees of the State of NJ and part-time faculty
members employed at New Jersey public institutions of higher
education; Fill in and Print
Employer Portion, Acrobat 4.0 or Higher Needed) |
| SHBP/SEHBP |
COBRA: High Deductible Health Plan (HDHP) Part-time Employee COBRA Application (for
part-time employees of the State of NJ and part-time faculty
members employed at New Jersey public institutions of higher
education; Fill in and Print
Employer Portion, Acrobat 4.0 or Higher Needed) |
SHBP/SEHBP |
COBRA:
State Intermittent Employee COBRA Application |
| SHBP/SEHBP |
COBRA:
High Deductible Health Plan (HDHP) State Intermittent Employee COBRA Application |
| SHBP/SEHBP |
COBRA:
High Deductible Health Plan (HDHP) State Intermittent Employee COBRA Application Fill in and Print
Employer Portion, Acrobat 4.0 or Higher Needed) |
SHBP/SEHBP |
COBRA:
Notice to Employees |
SHBP/SEHBP |
COBRA: FSA Plan Information for Employees |
SHBP/SEHBP |
COBRA: FSA Plan COBRA Notice and Election Form |
SHBP/SEHBP |
COBRA/HIPAA Required Notices to Enrollees |
SHBP/SEHBP |
COBRA:
Subsidy Roster |
SHBP/SEHBP |
Deletion
Transmittals Form with Instructions |
SHBP/SEHBP |
Dental:
Retiree Dental Expense Plan Member Handbook |
SHBP/SEHBP |
Dental:
NJ State Dental Expense Plan Claim Form |
SHBP/SEHBP |
Dental:
Providers Chart |
SHBP/SEHBP |
Dental: Program Book |
SHBP/SEHBP |
Dental:
Resolution for SHBP Dental Plan Participation |
SHBP/SEHBP |
Dental:
Resolution for SHBP Dental Plan Termination |
SHBP/SEHBP |
Federal
COBRA/HIPAA Required Notices to Enrollees |
SHBP/SEHBP |
HIPAA:
Certificate of Coverage |
SHBP/SEHBP |
HIPAA:
Notice of Coverage |
SHBP/SEHBP |
HIPAA:
Notice of Privacy Practices to Enrollees in the New Jersey SHBP/SEHBP |
SHBP/SEHBP |
HIPAA:
Member Authorization Form for Use and Disclosure of Protected and Private Information (Member Authorization Form) |
SHBP/SEHBP |
COBRA/HIPAA Required Notices to Enrollees |
SHBP/SEHBP |
Monthly
Change Summary |
SHBP/SEHBP |
Prescription
(Rx) Program Book |
SHBP/SEHBP |
Retiree
Certification of Coverage (for Emergency Room) |
| SHBP/SEHBP |
Resolution to Authorize Participation for Domestic Partnership Coverage under the SHBP/SEHBP |
SHBP/SEHBP |
Resolution:
Domestic Partner Health Benefits through a Non-SHBP Employer |
SHBP/SEHBP |
Resolution:
Rx Participation |
SHBP/SEHBP |
Resolution:
Terminate Rx Participation |
SHBP/SEHBP |
Resolution:
Premium Delay |
SHBP/SEHBP |
Resolution:
Change in Full Time Hours |
SHBP/SEHBP |
Resolution:
Authorization to Change the Percent of Premiums Paid for Employee and/or Dependent Coverage by Local Employer |
SHBP/SEHBP |
Resolution:
Authorization to Participate in SHBP/SEHBP |
SHBP/SEHBP |
Resolution:
Terminate Participation in SHBP/SEHBP |
SHBP/SEHBP |
Resolution:
Chapters 88 & 436 |
SHBP/SEHBP |
Resolution:
Chapter 48 with Instructions |
SHBP/SEHBP |
Resolution by Local Government Employers to Limit the Medical Plans Offered under the SHBP |
SHBP/SEHBP |
Resolution by Local Education Employers to Limit the Medical Plans Offered under the SEHBP |
SHBP/SEHBP |
Retired
Coverage Enrollment Application |
SHBP/SEHBP |
Retired
Change of Status Application |
SHBP/SEHBP |
SHBP/SEHBP
Coverage Waiver/Reinstatement Form (Local Government/Education) |
SHBP/SEHBP |
SHBP
Coverage Waiver/Reinstatement Form (State) |
SPRS
= State Policemen's Retirement System |
|
SPRS
|
Enrollment
Application |
|
SPRS |
Retirement:
Certification of Service & Final Salary |
TPAF
= Teachers Pension and Annuity Fund |
|
TPAF
|
Enrollment
Application |
|
TPAF |
GLI:
Application to Waive GLI in Excess of $50,000 |
|
TPAF |
GLI:
Application to Reinstate GLI in Excess of $50,000 |
|
TPAF
|
GLI:
Personal Life Insurance Premiums Remittance Form |
|
TPAF
|
GLI:
Withdrawal from Contributory Life Insurance Form |
|
TPAF
|
Leave
of Absence (LOA) Verification Form |
TPAF |
Purchase:
Employer Verification of Leave of Absence for Union Representation |
TPAF |
Purchase:
Authorization to Purchase Service Credit — Union Representation |
|
TPAF
|
Report
of Transfer/Multiple Enrollment |
|
TPAF
|
Report
of Transfer/Multiple Enrollment (Fill
in and Print, Acrobat 4.0 or Higher Needed) |
|
TPAF
|
Retirement:
Certification of Service and Final Salary |
TPAF |
Retirement: Change of Retirement (Date, Type, Option) |
TPAF |
Retirement: Authorization for Direct Deposit of Benefit Payment |
|
TPAF |
Retirement:
Request for Retirement Estimate |
|
TPAF
|
Retirement:
Request for Retirement Estimate
(Fill in and Print, Acrobat
4.0 or Higher Needed) |
