Forms

Overview

The Forms Library will serve as the central hosting and retrieval application for all LACERS forms and documentations. The Forms Library will allow external users to search and filter across a variety of categories with all forms/documentation available for download.

To submit your forms, visit the Secure Document Upload page here.

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Health Benefit Forms*

2022 Medical Plan Enrollment Form (Non-Kaiser)
2022 Medical Plan Enrollment Form (Kaiser)

2022 Medical/Dental Plan Cancellation Form
2022 Dental Plan Enrollment Form
2022 Open Enrollment Overview

2021 Medical Plan Enrollment Form (Non-Kaiser)
2021 Medical Plan Enrollment Form (Kaiser)
2021 Dental Plan Enrollment Form
Certification of Dependent or Survivor Status for Health Coverage
Medicare Information Acknowledgement Form

*Contact LACERS if you need enrollment forms for the following plans:

  • Anthem Blue Cross Life and Health
  • Kaiser Permanente Senior Advantage
  • UnitedHealthCare Medicare Advantage
  • SCAN Medicare Advantage
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Information Sheets

Back Contribution Information Sheet
Back Contribution Information Sheet for Participants of the Pension Savings Plan
Excess Benefit Program Fact Sheet
FDBP Information Sheet
Tier 1 - Government Service Buyback Information Sheet
Tier 3 - Government Service Buyback Information Sheet
Hiring Hall Service Credit Purchase Information Sheet
Public Service Buyback Information Sheet
Reciprocity Information Sheet
Re-deposit Information Sheet
Your LACERS Health Plan Subsidy

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Retirement Application (Tier 1 Members)

Tier 1 retirement applicants will use the online Retirement Application Portal (RAP) to apply for retirement. Please refer to the link below for detailed information about the process.

Applying for Retirement Online

Not sure what Tier you are a part of? Click here for more information.

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Retirement Application Forms

Tier 1 Enhanced retirement applicants and Deferred Vested retirement applicants, please refer to the following retirement application Do’s and Don’ts during the retirement process:

Retirement Application Do’s and Don’t’s for Tier 1 Enhanced and Deferred Vested applicants  
Do’s
    		Don’t’s
    • DO apply at the link below if you are a Tier 1 Enhanced or a Deferred Vested applicant
    • DO NOT apply at the link below if you are a Tier 1 Member, instead use the Retirement Application Portal
    • DO sign and date your application
    • DO NOT forget to sign your application
    • DO submit ALL three (3) pages of your Retirement Application
    • DO NOT use any white-out on your application
    • DO initial any cross-outs
    • DO NOT put a past date as your Retirement Effective Date
    • DO make sure your application is submitted within the filing period
    • DO NOT submit an illegible application

    Tier 1 Enhanced and Deferred Vested application submission
    Tier 1 Enhanced Retirement Application
    Deferred Vested Retirement Application
    Questionnaire for Tier 1 Enhanced Retirees
    Questionnaire for Vested Retirees
    Tier 1 Enhanced and Deferred Vested Retirement Information Sheet

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