Division of Risk Management and Insurance Services / Forms/Publications

Employee Forms

Enrollment & Dependent Forms

HB1 - Health Benefits Enrollment Form - Employees

HB1 - Health Benefits Enrollment Form - Employees.pdf 351.25 KB (Last Modified on January 12, 2024)

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HB5 - Health Benefits Enrollment Form - Half Time Employees

2023 Health Benefits Enrollment Form - Half-Time Active Employees V3.pdf 310.85 KB (Last Modified on December 26, 2023)

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HBA5 - Health Benefits Enrollment Form - TA's & Playground Aides

HBA5 - Health Benefits Enrollment Form - Units F and G.pdf 599.13 KB (Last Modified on January 5, 2024)

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HBA4 - Medical Opt-Out/Cash-Back Attestation for 2024

Only for the remainder of the 2024 calendar year. For more information, click here.

2024 Medical Opt-Out Cash Back Attestation Form - HBA4 REVISED.pdf 196.62 KB (Last Modified on January 29, 2024)

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HB7 - Request for Change of Dependent Status - Employees

2023 Request for Change of Dependent Status Active Employees - HB7.pdf 390.84 KB (Last Modified on December 26, 2023)

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HBA6 - Request for Change of Dependent Status - TA's & Playground Aides

2024 Request for Change of Dependent Status - Units F and G.pdf 275.9 KB (Last Modified on December 26, 2023)

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2024 Domestic Partner Information, Declaration, and Enrollment Form

2024 Active - Domestic Partner Information Declaration and Enrollment Packet.pdf 698.49 KB (Last Modified on June 13, 2024)

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2025 Domestic Partner Information, Declaration, and Enrollment Form

2025A Domestic Partner Information Declaration and Enrollment Packet.pdf 559.65 KB (Last Modified on November 1, 2024)

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2024 Enrollment Form - Substitute Employees

2024 Health Benefits Enrollment Form - Substitute Employees - fillable.pdf 480.99 KB (Last Modified on August 19, 2024)

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2024 Enrollment Form - Adult Ed HB1-FSTM1

2024 Health Benefits Enrollment Form - Adult Ed HB1-FSTM1 - fillable.pdf 720.55 KB (Last Modified on August 19, 2024)

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2024 Enrollment Form - Adult Ed HB1-FSTFL&M1TFL

2024 Health Benefits Enrollment Form - Adult Ed HB1-FSTFL and M1TFL - fillable.pdf 590.23 KB (Last Modified on August 19, 2024)

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Life Insurance, Deferred Compensation, and Flexible Spending Account Forms

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)

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Securian - Beneficiary Designation Form

LAUSD Bene Designation 83345_1022.pdf 714.82 KB (Last Modified on December 26, 2023)

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Securian - Service Request Form Supplemental

Service Request Form - Supplemental.pdf 271.74 KB (Last Modified on September 17, 2024)

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Securian - Service Request Form Basic

Service Request Form - Basic.pdf 140.36 KB (Last Modified on September 17, 2024)

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HB6 - Flexible Spending Account - Enrollment Form

2023 Active Flexible Spending Account Enrollment Form HB6.pdf 292.94 KB (Last Modified on December 26, 2023)

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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)

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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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Voya - 457(b) Beneficiary Designation Form

457b Beneficiary form LAUSD.pdf 97.65 KB (Last Modified on December 26, 2023)

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Retiree Forms

HBA1 - Retirement Eligibility Verification Form

Retirement Eligibility Verification Form - May 2023 - HBA1.pdf 228.1 KB (Last Modified on December 26, 2023)

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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)

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HBR10 - Retiree Change of Address

HBR10-Retiree_Change_of_Address.pdf 249.93 KB (Last Modified on December 27, 2023)

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HBR7 - Request for Change of Dependent Status - Retiree

2023 Request for Change of Dependent Status - Retirees - HBR7 - May 2023.pdf 335.82 KB (Last Modified on December 26, 2023)

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PO Box Address Form (Kaiser Permanente Senior Advantage)

Required by retirees and each of their >65 / Medicare-eligible dependents.

3. Kaiser PO Box Letter as of 11.02.23 web.pdf 210.75 KB (Last Modified on December 26, 2023)

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PO Box Attestation Form (Anthem Medicare Preferred PPO)

Required by retirees and each of their >65 / Medicare-eligible dependents.

4. Anthem PO Box Letter as of 11.02.23 web.pdf 217.71 KB (Last Modified on December 26, 2023)

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2024 Domestic Partner Information, Declaration, and Enrollment Form (Retiree)

2024 Retiree - Domestic Partner Information Declaration and Enrollment Packet.pdf 551.85 KB (Last Modified on June 13, 2024)

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2025 Domestic Partner Information, Declaration, and Enrollment Form (Retiree)

2025R Domestic Partner Information Declaration and Enrollment Packet.pdf 675.69 KB (Last Modified on November 1, 2024)

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Medicare Forms

Health Net Seniority Plus Enrollment Form

Health Net Enrollment Form.pdf 465.73 KB (Last Modified on December 26, 2023)

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Health Net Seniority Plus Disenrollment Form

Health Net Disenrollment Form.pdf 584.54 KB (Last Modified on December 26, 2023)

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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)

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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)

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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.

2024 Employee Benefits Information

Chart with all the benefits for 2024 calendar year.

2024 Retiree Benefits Guide

Retiree guide to all the benefits for 2024 calendar year.

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.

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