Actives and Adjuncts
Complete packet for new employees who want to enroll into Medical, Dental, Vision, and/or Life Insurance. Includes Enrollment/Change form (application), list of supporting documentation to add dependents, contact information for the LACCD Health Benefits Department and our carriers, life insurance application packet, and an opportunity to decline benefits. It is mandatory that you submit the Enrollment/Change form (or Declination of Health & Life Benefits if you decline benefits) and the Beneficiary Designation. All other forms are contingent upon your needs.
- Active Employees who have a qualifying life-changing event who need to add/remove dependents, add/change benefit plans, or request a change of address.
- Adjunct Application for New Adjunct Enrollment during the Fall/Spring special enrollment period or who need to make changes based on a qualifying life event.
Complete this form only if specifically requested by the Health Benefits Unit
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.