Benefits Forms & Documents
Below you will find links that will take you to various Benefits forms and documents.
General H & W Benefits Documents and Forms
- º£½ÇÉçÇøEmployee Benefits Guide
- º£½ÇÉçÇøBenefits Eligibility Acknowledgement Form
- Qualifying Life Event Requirements
- Health Insurance Declination - Waiver Form
- º£½ÇÉçÇøDomestic Partner Affidavit
- º£½ÇÉçÇøAnnual Notices Packet
- Open Enrollment Announcement
- Summary of Premium Costs & Contributions for H&W
- Open Enrollment Presentation
CHI/Part-Time Faculty Medical Insurance
- Cover Memo for CHI Benefits
- º£½ÇÉçÇøPT Adjunct Faculty Medical Coverage Enrollment Announcement 2024
- PT Faculty Medical Insurance Information
- º£½ÇÉçÇøInsurance Certification Form
- PT Faculty Enrollment Form - BC HMO Elements Bronze Plan
- BC HMO Elements Bronze Plan Benefits Summary Plan Description
- BC HMO Elements Bronze Plan Summary of Benefits Coverage
- PT Faculty GAP MONTHS
Anthem Blue Cross HMO – California Care
- Blue Cross HMO Enrollment Form
- BC HMO Summary Plan Description
- BC HMO Summary of Benefits Coverage
- BC HMO Evidence of Coverage
Anthem Blue Cross PPO – Prudent Buyer
- Blue Cross PPO Enrollment Form
- BC PPO Summary Plan Description
- BC PPO Summary of Benefits Coverage
- BC PPO Evidence of Coverage
Anthem Blue Cross Elements HMO – Part-Time, Bronze Plan Eligible Employees
- LBCCD Bronze Plan Open Enrollment Announcement
- Part-Time Employee Benefits Guide
- BC HMO Elements Bronze Plan Enrollment Form
- Bronze Plan Payment Terms Agreement
- BC HMO Elements Bronze Plan Benefits Summary Plan Description
- BC HMO Elements Bronze Plan Summary of Benefits Coverage
- BC HMO Bronze Plan Elements Evidence of Coverage
Blue Cross Claim and Order Forms
- Express Scripts Home Delivery Order Form
- How to Use Mail Order Rx
- Prescription Drug Reimbursement/Claim Form
- Member Claim Form
Kaiser Permanente
- Kaiser Permanente Enrollment/Change Form
- Kaiser Permanente Summary Plan Description
- Kaiser Permanente Summary of Benefits Coverage
- Kaiser Permanente Evidence of Coverage
- Kaiser The Active & Fit Direct Program
- Kaiser Healthy Balance Weight Management Program No Cost
- Kaiser Center for Healthy Living Programs
Delta Dental HMO – DeltaCare USA
- DeltaCare USA - Enrollment/Change Form
- DeltaCare USA - Evidence of Coverage
- Delta Care USA – Enrollee Notice
Delta Dental PPO – Incentive Plan
- Delta Dental PPO Enrollment/Change Form
- Delta Dental PPO Evidence of Coverage
- Delta Dental PPO Highlights
- How Delta Dental Incentive Plan Works
- Delta Dental PPO – Enrollee Notice
Anthem EAP-Employee Assistance Plan
Vision Service Plan (VSP) - No Enrollment Form Needed
Employer Paid Group Term Life Insurance
- º£½ÇÉçÇøGroup Term Life Enrollment/Beneficiary Change Form
- Anthem Blue Cross Basic Life and AD&D Summary Plan Description
- Anthem Blue Cross AD&D Certificate Booklet
- UNUM Basic Life & AD&D Summary
- UNUM Life and AD&D Booklet
Optional & Voluntary Plans
- Savings & Retirement Plans through Schools First FCU
- Unum Instructions For Enrolling in Voluntary Products
- Unum Voluntary Short Term Disability
- Unum Long Term Disability
- Unum Voluntary Life and AD&D
- Unum Evidence of Insurability (medical questionnaire)
- Unum Voluntary Plans Beneficiary Form
- MetLife Beneficiary Form
Retiree Benefits Information
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Information for Existing Retirees
Contact the Benefits Office at 562-938-4531 or 562-938-4465. - Retiree Annual Notices
- º£½ÇÉçÇøRetiree Benefits Guide
- º£½ÇÉçÇøPost-65 Retirees Benefits Guide
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(Start your retirement process with CalSTRS. Click on the link for instructions.)
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(Start your retirement process from CalPERS. Click on the link for instructions.)
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Applying for Medicare – All retirees that will receive district paid insurance and they or their spouse are 65 or over at time of retirement must apply for Medicare w/in 3 months prior to retiring from LBCC.
- Benistar Medicare
Watch Video:
(Passcode: aDSr#J8t)
Slideshow: Benistar Medicare - 2023 º£½ÇÉçÇø
- Ray Martin & Associates Medicare
Watch Video:
(Passcode: ?RRj%3zE)
Slideshow: Ray Martin & Associates '22 Medicare 101 - LBCC
- Kaiser Medicare
Watch Video:
Slideshow: Welcome_to_kaiser_permanente_presenting_medicare_101_LBCCD
- Benistar Medicare