Get Ca Lausd Health Benefits Enrollment Form 2022-2025

The CA LAUSD Health Benefits Enrollment Form is essential for active employees looking to enroll in health benefits. This guide provides a clear, step-by-step overview of how to complete the form online, ensuring that you understand each section and field thoroughly.

Follow the steps to complete the enrollment process effectively.

1. Click ‘Get Form’ button to access the Health Benefits Enrollment Form and open it for editing.
2. Begin by filling out your personal details in the appropriate fields. Include your employee number, name (last, first, middle initial), address, city, state, zip code, phone number, email address, and social security number.
3. Indicate your employment classification by checking the appropriate box—either 'Classified' or 'Certificated'.
4. In the health plans section, check the medical, dental, and vision plans you wish to enroll in. You may also select 'No Medical Coverage' or 'No Dental Coverage' as applicable.
5. If you wish to enroll dependents, provide their information including their last name, first name, middle initial, social security number, relationship to you, date of birth, and sex (indicate as M or F). Attach additional pages if necessary.
6. Verify that you have included the necessary documentation for dependent status as outlined in the instructions. Ensure that you provide verification as required for spouses, domestic partners, and children.
7. Sign and date the form where indicated, confirming that the information provided is accurate and that you understand the election's implications on your coverage.
8. Finally, save your changes, then download, print, or share the completed form as needed. Remember to return the form along with necessary documents to the Benefits Administration via fax or email.

Start your health benefits enrollment process online today by completing the CA LAUSD Health Benefits Enrollment Form!