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.


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
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)


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:

Retirement Application Do’s and Don’t’s for Tier 1 Enhanced and Deferred Vested applicants  
    • 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 - 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

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