Enrollment Form - Active DONE - lausdemployment 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Employee Number, Last Name, First Name, and Date of Birth in the designated fields. Ensure accuracy as this information is crucial for processing your application.
3. Fill in your Address, City, State, and Zip Code. This ensures that all correspondence reaches you without delay.
4. Select your Retirement Date and indicate whether you are applying for Service or Disability Retirement by checking the appropriate box.
5. Choose your desired Health Plans from the options provided. Make sure to review eligibility requirements for each plan before making a selection.
6. Complete the Dependent Information section if applicable. Remember that Social Security numbers are mandatory for all dependents listed.
7. If you or your spouse is over 65, fill out the Medicare Information section and attach a copy of the Medicare card as required.
8. Finally, sign and date the form at the bottom to confirm that all information is accurate and complete before submitting it to Benefits Administration.

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