Forms 

Actives and Adjuncts

2013 Enrollment/Change form for Actives and Adjuncts

2014 Enrollment/Change form for Actives and Adjuncts

Active employees, Adjuncts, and COBRA participants who want to add a new dependent or remove a dependent (as needed), or change their benefit plan (with a qualifying life-changing event), should complete and submit an Enrollment/Change form.

CalPERS HBD12-w-instructions  Complete this form only if specifically requested by the Health Benefits Unit

Active Employees

Certification of Video Display Terminal Use

Active employees whose work duties require them to use a computer for twenty or more hours per week should submit a Certification of Video Display Terminal Use.

Declaration of Declination of Health and Life Benefits

Employees who do not want health and/or life benefits through LACCD for themselves or their dependents should complete and submit a Declaration of Declination of Health and Life Benefits.

Note: you should only complete and submit this form if you do not already have health/life benefits and are refusing them. Do not use this form if you already have dental, medical and vision benefits and want to remove a dependent from your benefits.

If you want to remove a dependent from your benefits, please complete and submit an Enrollment/Change form instead, and use Change in Dependent Coverage as your reason for completing the form along with the appropriate Event/Life Status Change.

CalPERS HBD12-w-instructions. Complete this form only if specifically requested by the Health Benefits Unit

Cigna Life Insurance Application

Active Employees who wish to enroll in either Basic (District-paid) or Voluntary (employee pays the premium via paycheck deductions) Cigna Life Insurance should submit a Cigna Life Insurance application. Employees who apply for any life insurance benefit should also complete and submit Cigna's Beneficiary Designation form. Each time you wish to make a change to your beneficiaries, you should submit a new copy of this form. Employees who apply for voluntary life must complete and submit a copy of Cigna's Evidence of Insurability form.

To submit a life insurance claim, please complete the Cigna Claim Form.

Active Employees Planning to Retire

Application for Retiree Health Benefits

Employees who are retiring should complete and submit to the Health Benefits Unit an Application for Retiree Health Benefits to ensure that their health benefits will continue uninterrupted.

CalPERS HBD12-w-instructions. Complete this form only if specifically requested by the Health Benefits Unit

CMS-L564 Medicare over 65

Retirees and Survivors

2014 Enrollment/Change Form for Retirees and Survivors

Retirees and Survivors who have experienced any qualifying life-changing event and/or wish to add or delete a dependent should complete an Enrollment/Change form for Retirees and Survivors.

Retirees who wish to make any change to their medical benefits must do so through CalPERS. You should complete a copy of the CalPERS Health Plan Enrollment for Retirees form.

 CalPERS HBD12-w-instructions. Complete this form only if specifically requested by the Health Benefits Unit

 

#General Forms

Domestic Partner Forms

 
  • Affidavit (Common Form 07)

  • Tax Form (Common Form 08)