Full-Time (Active) Employees



Actives and Adjuncts
New Employee Health Benefits & Life Insurance Packet

Complete packet for new employees hwo 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.

Supplemental Application

1. 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.

2. 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.

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

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.

New York Life Insurance

Active Employees who wish to enroll in either Basic (District-paid) or Voluntary (employee pays the premium via paycheck deductions) New York Life Insurance should submit a New York Life Insurance application.

Employees who apply for any life insurance benefit should also complete and submit a New York Life 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 New York Life Evidence of Insurability form.