Get Ca Lausd Hi-22 2018-2026

This guide provides a comprehensive overview of how to accurately complete the CA LAUSD HI-22 form for health benefits continuation. Whether you are new to filling out online forms or familiar with the process, this user-friendly guide will help ensure that you complete the application correctly and efficiently.

Follow the steps to accurately fill out the CA LAUSD HI-22 form online.

1. Click ‘Get Form’ button to obtain the CA LAUSD HI-22 application for continuation of health benefits and open it in your preferred editing interface.
2. In the personal information section, provide your employee number, last name, first name, middle initial, date of birth, and social security number. Ensure all personal details are accurate and current.
3. Complete your current address, including city, state, and zip code, along with your phone number. This information is essential for communication regarding your application.
4. Indicate your retirement date and mark whether you are applying for service or disability retirement. This will determine your eligibility for specific health plans.
5. Select the health plans you wish to enroll in at the time of retirement from the list provided. Options include medical, dental, and vision coverage. Make sure to read the eligibility requirements for each plan.
6. If applicable, provide details for your dependents, including their social security numbers, names, dates of birth, relationships, and gender. Additional pages may be attached if necessary.
7. Complete the Medicare information section if you or your spouse is age 65 or older. Attach a copy of your Medicare card as required.
8. Indicate if your spouse or domestic partner is an LAUSD employee or retiree and provide their employee number if applicable.
9. Review the retirement system section and indicate whether you are part of the State Teachers Retirement System (STRS) or the Public Employees Retirement System (PERS).
10. Read and acknowledge the terms and conditions outlined in the form. Sign and date the application before submission. Make sure your signature is clear.
11. Finally, once you have completed all sections, you may save changes, download, print, or share the form as needed. Be sure to submit the completed form along with any required documents to the Benefits Administration.

Take action now and complete your CA LAUSD HI-22 form online to ensure a smooth continuation of your health benefits.