Health Benefit Forms*

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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

*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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