Division of Risk Management and Insurance Services
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- Los Angeles Unified School District
- Benefits Administration
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Employee FormsEnrollment & Dependent Forms
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HB1 - Health Benefits Enrollment Form - Employees
HB1 - Health Benefits Enrollment Form - Employees.pdf 437.32 KB (Last Modified on December 13, 2024) -
HB5 - Health Benefits Enrollment Form - Half Time Employees
HB5 - Health Benefits Enrollment Form - Half Time Employees.pdf 366.25 KB (Last Modified on December 13, 2024) -
HBA5 - Health Benefits Enrollment Form - TA's & Playground Aides
HBA5 - Health Benefits Enrollment Form - TAs and Playground Aides.pdf 684.65 KB (Last Modified on December 13, 2024) -
HB7 - Request for Change of Dependent Status - Employees
HB7 - Request for Change of Dependent Status - Employees.pdf 477.28 KB (Last Modified on December 9, 2024) -
HBA6 - Request for Change of Dependent Status - TA's & Playground Aides
HBA6 - Request for Change of Dependent Status - TAs and Playground Aides.pdf 361.77 KB (Last Modified on December 9, 2024) -
2025 Domestic Partner Information, Declaration, and Enrollment Form
2025A Domestic Partner Information Declaration and Enrollment Packet.pdf 646.49 KB (Last Modified on December 9, 2024)
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Life Insurance, Deferred Compensation, and Flexible Spending Account Forms
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Securian - Optional Life Insurance Enrollment Form
104856 Los Angeles Unified School District Term Life Enrollment 9-2023.pdf 1.27 MB (Last Modified on January 12, 2024) -
HB6 - Flexible Spending Account - Enrollment Form
2023 Active Flexible Spending Account Enrollment Form HB6.pdf 292.94 KB (Last Modified on December 26, 2023) -
HB12 - Flexible Spending Account - Request for Change Form
Flexible Spending Account Request for Change Form HB12.pdf 281.79 KB (Last Modified on December 26, 2023) -
Voya - 457(b) Enrollment Form
Voya_457b_Enrollment_Form_Updated 07182024 Revised.pdf 180.71 KB (Last Modified on September 3, 2024)
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Retiree Forms
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HBA1 - Retirement Eligibility Verification Form
Retirement Eligibility Verification Form - May 2023 - HBA1.pdf 228.1 KB (Last Modified on December 26, 2023) -
HI-22 - Application for Continuation of Health Benefits
Application for Continuation of Health Benefits HI-22.pdf 300.97 KB (Last Modified on April 19, 2024) -
HBR7 - Request for Change of Dependent Status - Retiree
2023 Request for Change of Dependent Status - Retirees - HBR7 - May 2023.pdf 424.02 KB (Last Modified on December 9, 2024) -
PO Box Address Form (Kaiser Permanente Senior Advantage)
Required by retirees and each of their >65 / Medicare-eligible dependents.
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PO Box Attestation Form (Anthem Medicare Preferred PPO)
Required by retirees and each of their >65 / Medicare-eligible dependents.
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2025 Domestic Partner Information, Declaration, and Enrollment Form (Retiree)
2025R Domestic Partner Information Declaration and Enrollment Packet.pdf 764.25 KB (Last Modified on December 9, 2024)
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Medicare Forms
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Kaiser Senior Advantage Disenrollment Form California
500860688_KPSAKPMAPprDsenrlForm_Medicare_MULTI_2021_Frm_ATC_09.08.2021 CA.pdf 73.78 KB (Last Modified on December 26, 2023) -
Kaiser Senior Advantage Disenrollment Form Hawaii
500860688_KPSAKPMAPprDsenrlForm_Medicare_MULTI_2021_Frm_ATC_09.08.2021 HI.pdf 79.77 KB (Last Modified on December 26, 2023) -
Kaiser Senior Advantage Disenrollment Form Northwest
500860688_KPSAKPMAPprDsenrlForm_Medicare_MULTI_2021_Frm_ATC_09.08.2021 NW.pdf 85.75 KB (Last Modified on December 26, 2023)
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Health Benefit Guides
2025 Employee Benefits Information
Chart with all the benefits for 2025 calendar year.
2025 Retiree Benefits Guide
Retiree guide to all the benefits for 2025 calendar year.
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Helpful Resources
New Hire Checklist
Welcome! Find helpful tips to getting your benefits started!
Retirement Checklist
Planning to retire? Here is a list of things to do to enroll in retirement health benefits.
Retirement Reminders
Stay informed of important requirements to maintain your District-sponsored health benefits.
When an Employee/Retiree Passes Away
A step-by-step guide to reporting the death of a loved one and applying for any potential death benefits.
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Publications
Coverage Information
Find Summary of Benefits and Coverage, Evidence of Coverage, Prescription Coverage, and more.
Health Benefit Provider Flyers
Find resources from different Medical Providers
COBRA Rates
Premium Information for Employees and Retirees