Member and Retiree
Account Access

Employer Forms and Publications

Some forms can be submitted online electronically. To submit a form online you will need to have an Employer PERSI web account. Click on the icon for the form to login or to register.

Memos to Employers

• Benefits at a Glance
• Required Footnote Disclosure for Audited Fiscal Year 2014 Financial Statements 08/15/2014

Forms

Forms	PDF
RS102 Membership Application - Only for use by Employers that submit paper transmittals.
RS110 Address change
RS115 Beneficiary Designation (for your employees to fill out)
RS118 Certification of Police Officer Status (PDF Fill-in Version)
RS118A Certification of PERSI Firefighter Status (PDF Fill-in Version)
RS119 Optional Retirement Plan (ORP) Sick Leave Submission
RS119JR Judicial Retiree Sick Leave Submission
RS130 Certification of City or County Employee's 8-Month Seasonal Status
RS132 Certification of Employment of a Retired Member
RS132A Certification of Employment of a Retired School Teacher or Administrator
RS211 School District / Charter School Sick Leave Policy Certification
RS415 Request for Premium Payments through the ORP Unused Sick Leave Program
RS432C Insurance Carrier Certification of Group Insurance Policy
RS432R Employer / Consortium Certification of Group Insurance Policy
Easy Pay - PERSI's Electronic Payment System
PERSI Employers Forms Version Log