Beneficiary Forms
Current Employees
Designation of Beneficiary for Active Members - Tier 1
Retirees
Designation of Beneficiary for Accrued Allowance of Surviving Spouse or Domestic Partner
Designation of Beneficiary for Unused Contributions and Accrued Payments
Designation of Beneficiary for Community Property
Designation of Beneficiary for Funeral Expense Allowance
Health Benefit Forms*
2022 Medical Plan Enrollment Form (Non-Kaiser)
2022 Medical Plan Enrollment Form (Kaiser)
2022 Medical/Dental Plan Family Account Change Form
2022 Medical/Dental Plan Cancellation Form
2022 Dental Plan Enrollment Form
2022 Open Enrollment Overview
2021 Medical/Dental Family Account Change Form
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
*Additional forms are needed if enrolling in one of LACERS’ Medicare plans. Contact LACERS to get these forms or they are available at the links below for the following plans:
2022 Kaiser Senior Advantage HMO form (the 2022 Kaiser form is valid for CALIFORNIA
REGION ONLY)
2022 Anthem Blue Cross Medicare Preferred (PPO) (for those with Medicare Parts A & B; enrollment form
is within packet, near the end)
2022 UnitedHealthcare Medicare Advantage HMO – Southern California (Please contact LACERS for the enrollment forms
specific to UnitedHealthcare Northern California, Nevada, or
Arizona)
2022 SCAN Health Plan Medicare Advantage HMO
2022 Anthem Blue Cross Medicare Prescription Enrollment (for those with Medicare Part B, ONLY, enrolling in
the Anthem Medicare PPO or Anthem HMO; enrollment form within
packet)
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
Larger Annuity Program
Larger Annuity - Initiation or Change of Contribution Amount
Larger Annuity - Distribution Election Form
Larger Annuity - Direct Deposit Authorization
Larger Annuity - Election to Change Investment Option or Terminate Bi-Weekly Contributions
Tax Notification
Trustee-to-Trustee Transfer/Direct Rollover Form For Larger Annuity
Larger Annuity Fact Sheet
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.
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:
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Do’s
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Don’t’s |
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Tier 1 Enhanced and Deferred Vested application submission
Tier 1 Enhanced - Airport Peace Officer Service 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