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