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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 2016-2017
2. LBCC Benefits Eligibility Acknowledgement Form PDF  
3. Health Insurance Declination - Waiver Form PDF 2015-2016
4. LBCC Domestic Partner Affidavit PDF  
5. LBCC Annual Notices Packet PDF 2015-2016
6. Insurance Carriers Contact Information PDF Revised 9/9/14
7. Open Enrollment Announcement PDF 2016-2017
Benefit Presentation Videos
1. Kaiser/MHN/Delta/VSP Education Workshop Link to YouTube  
2. Anthem/MHN/Delta/VSP Education Workshop Link to YouTube  
Kaiser Permanente
1. Kaiser Permanente Enrollment/Change Form PDF  
2. Kaiser Permanente Summary Plan Description PDF 2015-2016
3. Kaiser Permanente Summary of Benefits Coverage PDF 2015-2016
4. Kaiser Permanente Evidence of Coverage PDF 2015-2016
5. Preventive Services Coverage PDF 2013-2014
Anthem Blue Cross Elements HMO - Bronze Plan For Adjunct Faculty
1. Bronze Plan Open Enrollment Announcement (includes rates) PDF 2015-2016
2. BC HMO Elements Bronze Plan Enrollment Form PDF
3. BC HMO Elements Bronze Plan Payment Terms PDF
4. BC HMO Elements Bronze Plan Benefits Summary Plan Description and Summary of Benefits Coverage PDF 2015-2016
5. BC HMO Bronze Plan Elements Evidence of Coverage PDF 2015-2016
Anthem Blue Cross HMO - California Care
1. Anthem Blue Cross Enrollment/Change Form PDF  
2. BC HMO Summary Plan Description PDF 2015-2016
3. BC HMO Summary of Benefits Coverage PDF 2015-2016
4. BC HMO Evidence of Coverage PDF 2015-2016
5. Express Scripts Mail Order Rx Form PDF  
6. How to Use Mail Order Rx PDF  
7. Preventive Health Care Services PDF  
Anthem Blue Cross PPO - Prudent Buyer
1. Anthem Blue Cross Enrollment/Change Form PDF  
2. BC PPO Summary Plan Description PDF 2015-2016
3. BC PPO Summary of Benefits Coverage PDF 2015-2016
4. BC PPO Evidence of Coverage PDF 2015-2016
5. Express Scripts Mail Order Rx Form PDF  
6. How to Use Mail Order Rx PDF  
7. Preventive Health Care Services PDF  
Delta Dental HMO - DeltaCare USA
1. DeltaCare USA - Enrollment/Change Form PDF  
2. DeltaCare USA - Evidence of Coverage PDF 2014-2015
Delta Dental PPO - Incentive Plan
1. Delta Dental PPO Enrollment/Change Form PDF  
2. Delta Dental PPO Evidence of Coverage PDF 2014-2015
3. Delta Dental PPO Highlights PDF 2014-2015
4. How Delta Dental Incentive Plan Works PDF 2013-2014
Managed Health Network (MHN) - No Enrollment Form Needed
1. MHN Employee Assistance Program- All PDF 2014-2015
2. MHN EOC- All PDF 2014-2015
Vision Service Plan (VSP) - No Enrollment Form Needed
1. VSP Summary-All PDF 2014-2015
2. VSP Out-of-Network Claim Form PDF  
Group Term Life Insurance
1. Anthem Blue Cross Basic Life and AD&D Summary Plan Description PDF July 1, 2014 (Provides $25,000)
2. Anthem Blue Cross AD&D Certificate Booklet PDF July 1, 2014 (Provides $25,000)
3. UNUM Basic Life & AD&D Summary PDF July 1, 2014 (Provides $75,000)
4. UNUM Life and AD&D Booklet PDF July 1, 2014 (Provides $75,000)
Benefit Costs
1. Summary of Premium Costs & Contributions for H&W PDF 2015-2016
2. Classified and Management H&W Contributions PDF 2015-2016
3. Faculty H&W Contributions PDF 2015-2016
4. Blue Cross PPO - Active and COBRA Rates PDF 2015-2016
5. Blue Cross HMO - Active and COBRA Rates PDF 2015-2016
6. Kaiser Permanente - Active and COBRA Rates PDF 2015-2016
7. COBRA Rates-All Plans PDF 2015-2016
Retiree Benefits Information
1. CCA Retiree Options and Benefits FAQ PDF  
2. Classified Employee Election of Retiree Medical Benefits PDF Form HR034; revised 11/16
3. Q&A About Benefits of Classified Members Upon Retirement PDF 2014-2015
4.

CalSTRS direct link to myCALSTRS - to manage your Account

myCalSTRS - Manage Your Account

   
Section 125 Plans - Flexible Spending Accounts
1. Open Enrollment for Flexible Spending Accounts – 2017 Plan Year Announcement
PDF 
10/31/2016
2. FSA Web Enrollment Instructions PDF
10/31/2016
3. FSA Open Enrollment Form PDF

4. FSA Calculator - Helps you plan the amount you want to set aside with each paycheck Link 10/28/2016
5. FSA Employee Handout
PDF
10/28/2016
6. Dependent Care Employee Handout
PDF
10/28/2016
7. FSA Employee Guide - Brief description of a flexible spending account and the two common types being offered PDF
10/28/2016
8. Flexible Spending Account –FAQ
PDF
10/28/2016
9. Grace Period FAQ
PDF
10/28/2016
Affordable Care Act - The Marketplace
1. LBCC ACA Exchange Notice PDF 10/01/2013
2. Navigating the Maze - Employee Handout PDF 10/01/2013
3. Covered California Fact Sheet PDF 10/01/2013
4. Covered California - Changes in Health Insurance January 2014 PDF 10/01/2013
5. Covered California - How Financial Assistance Works PDF 10/01/2013
6. Covered California - Getting Financial Help PDF 10/01/2013
7. Covered California - Tribal Fact Sheet PDF 10/01/2013
Other Benefits Documents
1. California Guaranty Association Notices PDF  
2. Futuris Trust Summary Annual Report PDF September 2009
3. Futuris Benefit Trust PDF 7/1/08 - 6/30/09
4. PARS Financial Report PDF June 2009
5. Prudential's Accidental Death and Dismemberment Certificate of Coverage PDF 2013
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