Los angeles unified school district 2025

1. Click ‘Get Form’ to open the application in our editor.
2. Begin by entering your Employee Number, Last Name, First Name, and other personal details such as Address, City, State, Zip Code, Date of Birth, and Phone Number. Ensure accuracy as this information is crucial for processing your application.
3. Select your retirement type (Service or Disability) and indicate your Retirement Date. This helps determine your eligibility for health benefits.
4. In the Health Plans section, choose the medical plan you wish to enroll in at retirement. Review the options carefully to ensure they meet your needs.
5. Fill out the Dependent Information section if applicable. Include Social Security numbers and other required details for each dependent.
6. Complete the Medicare Information section if you or your spouse is over 65. Attach a copy of the Medicare card as required.
7. Finally, sign and date the form at the bottom to authorize processing. Remember that this form will not be processed unless signed.

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