Hi22 2026

The document is an application form for the continuation of health benefits for employees of the Los Angeles Unified School District (LAUSD) upon retirement. It outlines the necessary information required from the employee, including personal details, retirement date, selected health plans, and dependent information. The form also specifies eligibility requirements for retiree health benefits based on years of service and Medicare enrollment. Additionally, it provides instructions for submitting the application and maintaining coverage.

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Click ‘Get Form’ to open the hi22 application in the editor.
Begin by entering your Employee Number, Last Name, First Name, and Date of Birth in the designated fields. Ensure all personal information is accurate.
Select your retirement type (Service or Disability) and provide your Retirement Date. This information is crucial for processing your benefits.
In the Health Plans section, choose the medical, dental, and vision plans you wish to enroll in at retirement. Make sure to review eligibility requirements for each plan.
Fill out the Dependent Information section if applicable. Include Social Security numbers and other required details for each dependent.
Complete the Medicare Information section if you or your spouse is over 65. Provide necessary Medicare Claim Numbers and effective dates.
Finally, sign and date the form at the bottom to confirm that all information provided is accurate before submitting it to Benefits Administration.

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