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*
2021 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
2020 Medical/Dental Family Account Change Form
2020 Medical Plan Enrollment Form (Non-Kaiser)
2020 Medical Plan Enrollment Form (Kaiser)
2020 Dental Plan Enrollment Form
2020 Medical/Dental Cancellation 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
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
Retirement Application Forms
Before accessing the Managed Service Retirement Application or the Vested Service Retirement Application, please note that your retirement effective date must occur by October 31, 2020, or you will have to wait until February 1, 2021 when the SIP Period ends to apply for a non-SIP retirement. Please click here for more details.
Managed Service Retirement Application
Vested Service Retirement Application
Questionnaire for New Retirees - All Members
Questionnaire for Vested Retirees - All Members
Member Information Sheet