Employers' Pensions and Benefits Administration Manual (EPBAM)
   

 

Shortcuts

Information by Employer Task

Forms Index



Listed by Fund
  • 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

Provider Election and Allocation Form

ABP
Choosing between the PERS and ABP

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
ABP Long-Term Disability Form
ABP
ABP Withdrawal Request 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

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

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

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
Federal COBRA/HIPAA Required Notices to Enrollees
SHBP/SEHBP
COBRA: Assistance Eligibility Request Form
SHBP/SEHBP
COBRA: Assistance Eligibility Waiver Form

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: 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: State Intermittent Employee COBRA Application
SHBP/SEHBP COBRA: High Deductible Health Plan (HDHP) State Intermittent Employee COBRA Application

SHBP/SEHBP

COBRA: Notice to Employees

SHBP/SEHBP

Deletion Transmittals Form with Instructions

SHBP/SEHBP
Dental: Retiree Dental Plans 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

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 SHBP/SEHBP Applications and Forms

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

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)

BACK TO TOP

BACK TO HOME PAGE


division (internet use only): p&b home | SHBP home | forms and publications | seminars | contact the division
pension funds : PERS | TPAF | PFRS | SPRS | JRS | ABP | other funds | search
Last Updated: November 5, 2014