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

To enroll in the Kaiser or Kaiser Senior Advantage Plan*, please use: 

2024 Medical Plan Enrollment Form (Kaiser) for 2024 plan year

To enroll in Anthem Blue Cross HMO or PPO, UnitedHealthcare, SCAN, or Anthem Blue Cross Medicare Preferred (PPO)*, please use:

2024 Medical Plan Enrollment Form (Non-Kaiser) for 2024 plan year

Covering dependents (medical and/or dental)? Complete and submit Certification of Dependent or Survivor Status for Health Coverage with:

  • A copy of your certified marriage Certificate or Proof of Domestic Partnership
  • A copy of your child’s birth certificate
  • Proof of your child’s disability, if applicable

Retired Members and Survivors and dependents with Medicare Complete and submit the Medicare Information Acknowledgement Form in addition to senior forms*.

To enroll in either the DeltaCare USA HMO or the Delta Dental PPO dental plan:

2024 Dental Plan Enrollment Form for 2024 plan year

Add or Delete Dependents* from Your Medical and/or Dental Plan - Forms are required to be submitted by the 10th of the month to be effective the 1st of the following month. If enrolled in Medicare Parts A&B or Part B only, please contact Health at LACERS.Health@lacers.org for the required form. If adding dependent(s), please read the Health Benefits Guide or Health Benefits Guide Supplement (if applicable) for the cost of adding dependent(s), and see above for the additional required forms.

 for 2024 plan year

Cancel/Disenroll your Medical or Dental Plan* - Forms are required to be submitted by the 10th of the month to be effective the 1st of the following month. If enrolled in Medicare Parts A&B or Part B only, please contact Health at LACERS.Health@lacers.org for the required form. If adding dependent(s), please read the Health Benefits Guide or Health Benefits Guide Supplement (if applicable) for the cost of adding dependent(s), and see above for the additional required forms.

2024 Medical/Dental Plan Cancellation Form for 2024 plan year

Senior Enrollment Forms

2024 Kaiser Senior Advantage HMO form

2024 Anthem Blue Cross Medicare Preferred (PPO)(for those with Medicare Parts A & B)

2024 Anthem Blue Cross Medicare Prescription Enrollment (for those with Medicare Part B ONLY, enrolling in the Anthem Medicare PPO, Anthem HMO, or for those with Medicare Parts A & B enrolling in the Anthem Life & Health Medicare Supplemental Plan)

2024 UnitedHealthcare Medicare Advantage HMO - Southern California

2024 SCAN Health Plan Medicare Advantage HMO

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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 - Service Retirement Application (Airport Peace Officer)
    Tier 1 Enhanced - Vested Retirement Application (Airport Peace Officer)
    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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    Tax Forms

    Only the first page (page 1) of tax withholding forms W-4P and DE-4P are necessary for submission. 

    W-4P Federal Withholding Form
    DE-4P State Withholding Form
    Form W-9 Request for Taxpayer Identification Number and Certification
    Form W-9 Instructions

    IMPORTANT NOTE: These forms must be received in our office on or before the 12th of the month for your request to take effect in the same month. If received after the 12th, it will take effect the following month.

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