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LACERS Opt-Out Form for Open Enrollment Materials only

Each October, LACERS sends you an Open Enrollment packet to assist you in making health plan decisions for the coming plan year. This packet consists of a Health Plan Statement, Open Enrollment Overview, and Health Benefits Guide.

As a convenience to Retired Members and in an effort to reduce the use of resources, you can now opt-out of receiving a printed copy of some of your Open Enrollment materials (Health Benefits Guide and Open Enrollment Overview).

If you choose to opt-out of receiving these paper Open Enrollment materials, please complete the fields below and click the Submit button.

Beginning this coming Open Enrollment period: (Select one of the two options below):

In place of printed copies of the Open Enrollment materials, I would like LACERS to email me links to electronic (PDF) versions of the materials directly to my email address:
   
I do not wish to receive Open Enrollment materials by mail or email. I choose to visit the LACERS Retired Member homepage (www.lacers.org/retired) to view and download these materials when they become available.

You do not need to complete this form if you would like to continue receiving printed copies of your Open Enrollment materials.

My above selection will remain in effect until I notify LACERS otherwise.

(Name as it appears on your LACERS retirement allowance/continuance)
First Name: Middle Initial: Last Name:

Phone Number: (xxx-xxx-xxxx format)
Select if this is a new phone number:


Date of Birth: (mm/dd/yyyy format)