Beneficiary Forms
Current Employees
Designation of Beneficiary for Active Members
Retirees
Designation of Beneficiary for Accrued Allowance of Surviving Spouse or Domestic Partner
Designation of Beneficiary for Unused Contributions and Accrued Payments
Designation of Beneficiary for Community Property
Designation of Beneficiary for Funeral Expense Allowance
Health Benefit Forms
To enroll in the Kaiser or Kaiser Senior Advantage Plan*, please use:
2024 Medical Plan Enrollment Form (Kaiser) for 2024 plan year
2025 Medical Plan Enrollment Form (Kaiser) for 2025 plan year
To enroll in Anthem Blue Cross HMO or PPO, UnitedHealthcare, SCAN, or Anthem Blue Cross Medicare Preferred (PPO)*, please use:
2024 Medical Plan Enrollment Form (Non-Kaiser) for 2024 plan year
2025 Medical Plan Enrollment Form (Non-Kaiser) for 2025 plan year
Covering dependents (medical and/or dental)? Complete and submit Certification of Dependent or Survivor Status for Health Coverage with:
- A copy of your certified marriage Certificate or Proof of Domestic Partnership
- A copy of your child’s birth certificate
- Proof of your child’s disability, if applicable
Retired Members and Survivors and dependents with Medicare Complete and submit the Medicare Information Acknowledgement Form in addition to senior forms*.
To enroll in either the DeltaCare USA HMO or the Delta Dental PPO dental plan:
2024 Dental Plan Enrollment Form for 2024 plan year
2025 Dental Plan Enrollment Form for 2025 plan year
Add or Delete Dependents* from Your Medical and/or Dental Plan - Forms are required to be submitted by the 10th of the month to be effective the 1st of the following month. If enrolled in Medicare Parts A&B or Part B only, please contact Health at LACERS.Health@lacers.org for the required form. If adding dependent(s), please read the Health Benefits Guide or Health Benefits Guide Supplement (if applicable) for the cost of adding dependent(s), and see above for the additional required forms.
2024 Medical/Dental Plan Family Account Change Form for 2024 plan year
2025 Medical/Dental Plan Family Account Change Form for 2025 plan year
Cancel/Disenroll your Medical or Dental Plan* - Forms are required to be submitted by the 10th of the month to be effective the 1st of the following month. If enrolled in Medicare Parts A&B or Part B only, please contact Health at LACERS.Health@lacers.org for the required form. If adding dependent(s), please read the Health Benefits Guide or Health Benefits Guide Supplement (if applicable) for the cost of adding dependent(s), and see above for the additional required forms.
2024 Medical/Dental Plan Cancellation Form for 2024 plan year
2025 Medical/Dental Plan Cancellation Form for 2025 plan year
Senior Enrollment Forms
2024 Kaiser Senior Advantage HMO Form
2025 Kaiser Senior Advantage HMO Form
2024 Anthem Blue Cross Medicare Preferred (PPO)(for those with Medicare Parts A & B)
2025 Anthem Blue Cross Medicare Preferred (PPO) (for those with Medicare Parts A & B)
2024 Anthem Blue Cross Medicare Prescription Enrollment (for those with Medicare Part B ONLY, enrolling in the Anthem Medicare PPO, Anthem HMO, or for those with Medicare Parts A & B enrolling in the Anthem Life & Health Medicare Supplemental Plan)
2025 Anthem Blue Cross Medicare Prescription Enrollment(for those with Medicare Part B ONLY, enrolling in the Anthem Medicare PPO, Anthem HMO, or for those with Medicare Parts A & B enrolling in the Anthem Life & Health Medicare Supplemental Plan)
2024 UnitedHealthcare Medicare Advantage HMO - Southern California
2025 UnitedHealthcare Medicare Advantage HMO - Southern California
Information Sheets
Back Contribution Information Sheet
Back Contribution Information Sheet for Participants of the Pension Savings Plan
Excess Benefit Program Fact Sheet
Tier 1 - Government Service Buyback Information Sheet
Tier 3 - Government Service Buyback Information Sheet
Hiring Hall Service Credit Purchase Information Sheet
Larger Annuity Fact Sheet
Public Service Buyback Information Sheet
Reciprocity Information Sheet
Re-deposit Information Sheet
Medical Premium Reimbursement Program Information Sheet
Larger Annuity Program
Larger Annuity - Initiation or Change of Contribution Amount
Larger Annuity - Distribution Election Form
Larger Annuity - Direct Deposit Authorization
Larger Annuity - Election to Change Investment Option or Terminate Bi-Weekly Contributions
Tax Notification
Trustee-to-Trustee Transfer/Direct Rollover Form For Larger Annuity
Larger Annuity Fact Sheet
Retirement Application (Tier 1 Members)
Tier 1 retirement applicants will use the online Retirement Application Portal (RAP) to apply for retirement. Please refer to the link below for detailed information about the process.
Applying for Retirement Online
Not sure what Tier you are a part of? Click here for more information.
Retirement Application Forms
Tier 1 Enhanced retirement applicants and Deferred Vested retirement applicants, please refer to the following retirement application Do’s and Don’ts during the retirement process:
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Tier 1 Enhanced and Deferred Vested application submission
Tier 1 Enhanced - Service Retirement Application (Airport Peace Officer)
Tier 1 Enhanced - Vested Retirement Application (Airport Peace Officer)
Deferred Vested Retirement Application
Questionnaire for Tier 1 Enhanced Retirees
Questionnaire for Vested Retirees
Tier 1 Enhanced and Deferred Vested Retirement Information Sheet
Tax Forms
Only the first page (page 1) of tax withholding forms W-4P and DE-4P are necessary for submission.
W-4P Federal Withholding Form
DE-4P State Withholding Form
Form W-9 Request for Taxpayer Identification Number and Certification
Form W-9 Instructions
IMPORTANT NOTE: These forms must be received in our office on or before the 12th of the month for your request to take effect in the same month. If received after the 12th, it will take effect the following month.