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Benefits Forms and Documents
Human Resources

Below you will find links that will take you to various Benefits forms and documents.

Benefits Documents
General H & W Benefits Documents and Forms Revised Date
1. LBCC Employee Benefits Guide PDF 2017-2018
2. LBCC Benefits Eligibility Acknowledgement Form PDF  
3. Health Insurance Declination - Waiver Form PDF 2017-2018
4. LBCC Domestic Partner Affidavit PDF  
5. LBCC Annual Notices Packet PDF 2017-2018
6. Insurance Carriers Contact Information PDF Revised 4/26/2017
7. Open Enrollment Announcement PDF 2017-2018
Kaiser Permanente
1. Kaiser Permanente Enrollment/Change Form PDF  
2. Kaiser Permanente Summary Plan Description PDF 2017-2018
3. Kaiser Permanente Summary of Benefits Coverage PDF 2017-2018
4. Kaiser Permanente Evidence of Coverage PDF
Anthem Blue Cross Elements HMO - Bronze Plan For Adjunct Faculty
1. Bronze Plan Open Enrollment Announcement (includes rates) PDF 2017-2018
2. BC HMO Elements Bronze Plan Enrollment Form PDF
3. BC HMO Elements Bronze Plan Payment Terms PDF 2017-2018
4. BC HMO Elements Bronze Plan Benefits Summary Plan Description PDF 2017-2018
5. BC HMO Elements Bronze Plan Summary of Benefits Coverage PDF 2017-2018
6. BC HMO Bronze Plan Elements Evidence of Coverage PDF  
Anthem Blue Cross HMO - California Care
1. Blue Cross HMO Enrollment Form PDF 05/05/2017
2. BC HMO Summary Plan Description PDF 2017-2018
3. BC HMO Summary of Benefits Coverage PDF 2017-2018
4. BC HMO Evidence of Coverage PDF
Anthem Blue Cross PPO - Prudent Buyer
1. Blue Cross PPO Enrollment Form PDF 05/05/2017
2. BC PPO Summary Plan Description PDF 2017-2018
3. BC PPO Summary of Benefits Coverage PDF 2017-2018
4. BC PPO Evidence of Coverage PDF
Blue Cross Claim and Order Forms
1. Express Scripts Home Delivery Order Form PDF 05/05/2017
2. How to Use Mail Order Rx PDF  
3. Prescription Drug Reimbursement/Claim Form PDF 05/05/2017
4. Member Claim Form PDF
05/05/2017
Delta Dental HMO - DeltaCare USA
1. DeltaCare USA - Enrollment/Change Form PDF 05/09/2017
2. DeltaCare USA - Evidence of Coverage PDF
Delta Dental PPO - Incentive Plan
1. Delta Dental PPO Enrollment/Change Form PDF 05/09/2017
2. Delta Dental PPO Evidence of Coverage PDF
3. Delta Dental PPO Highlights PDF
4. How Delta Dental Incentive Plan Works PDF
Managed Health Network (MHN) - No Enrollment Form Needed
1. EAP Overview PDF
2. Behavioral Health Benefit PDF

3. Wellness Coaching PDF

2. MHN Evidence of Coverage PDF
Vision Service Plan (VSP) - No Enrollment Form Needed
1. VSP Summary-All PDF
2. VSP Out-of-Network Claim Form PDF  
Employer Paid Group Term Life Insurance
1. LBCC Group Term Life Enrollment/Beneficiary Change Form
PDF

2. Anthem Blue Cross Basic Life and AD&D Summary Plan Description PDF (Provides $25,000)
3. Anthem Blue Cross AD&D Certificate Booklet PDF (Provides $25,000)
4. UNUM Basic Life & AD&D Summary PDF (Provides $75,000)
5. UNUM Life and AD&D Booklet PDF (Provides $75,000)
Benefit Costs
1. Summary of Premium Costs & Contributions for H&W PDF 2017-2018
2. Classified and Management H&W Contributions PDF 2017-2018
3. Faculty H&W Contributions PDF 2017-2018
Optional & Voluntary Plans
1. Section 125 Plans – Flex Spending Accounts Enrollment Kit


2. Savings & Retirement Plans through Schools First FCU
PDF

3. Unum Instructions For Enrolling in Voluntary Products
PDF
4. Unum Voluntary Short Term Disability
PDF
5. Unum Long Term Disability
PDF
6. Unum Voluntary Life and AD&D
PDF
7. Unum Evidence of Insurability (medical questionnaire)
PDF
Retiree Benefits Information
1. Information for Existing Retirees
Contact the Benefits Office at 562-938-4531 or 562-938-4465.

2. CCA Retiree Benefits Options FAQ PDF 05/02/2016
3. Retiring with CalSTRS (Start your retirement process with CalSTRS.  Click on the link for instructions.)
http://www.calstrs.com/benefits-planning

4. AFT& MGT Retiree Benefit Options FAQ PDF 03/24/2017
5. Retiring with CalPERS (Start your retirement process from CalPERS. Click on the link for instructions.)
https://www.calpers.ca.gov/page/life-events/retirement

6. 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.
PDF
See attached 2017 Medicare & You Handbook for instructions.
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