Benefits Forms & Documents

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

General H & W Benefits Documents and Forms

  1. LBCC Employee Benefits Guide
  2. LBCC Benefits Eligibility Acknowledgement Form
  3. Qualifying Life Event Requirements
  4. Health Insurance Declination - Waiver Form
  5. LBCC Domestic Partner Affidavit
  6. LBCC Annual Notices Packet
  7. Open Enrollment Announcement
  8. Notification of Qualifying Event Form
  9. Summary of Premium Costs & Contributions for H&W
  10. Open Enrollment Presentation

CHI/Part-Time Faculty Medical Insurance

  1. Cover Memo for CHI Benefits
    ​1b.  Cover Memo for CHI Benefits – Late Start – March 2024
    1c. Cover Memo for CHI Benefits – Late Start – April 2024
  2. LBCC PT Adjunct Faculty Medical Coverage Enrollment Announcement 2024
    2b. ​LBCC PT Adjunct Faculty Medical Coverage Enrollment Announcement-LATE START-March 2024
    2c. LBCC PT Adjunct Faculty Medical Coverage Enrollment Announcement – Late Start – April 2024
  3. PT Faculty Medical Insurance Information
  4. LBCC Insurance Certification Form
  5. PT Faculty Enrollment Form - BC HMO Elements Bronze Plan
  6. BC HMO Elements Bronze Plan Benefits Summary Plan Description
  7. BC HMO Elements Bronze Plan Summary of Benefits Coverage
  8. PT Faculty GAP MONTHS

Anthem Blue Cross HMO – California Care

  1. Blue Cross HMO Enrollment Form
  2. BC HMO Summary Plan Description
  3. BC HMO Summary of Benefits Coverage
  4. BC HMO Evidence of Coverage

Anthem Blue Cross PPO – Prudent Buyer

  1. Blue Cross PPO Enrollment Form
  2. BC PPO Summary Plan Description
  3. BC PPO Summary of Benefits Coverage
  4. BC PPO Evidence of Coverage

Anthem Blue Cross Elements HMO – Part-Time, Bronze Plan Eligible Employees

  1. LBCCD Bronze Plan Open Enrollment Announcement 2023
  2. Part-Time Employee Benefits Guide
  3. BC HMO Elements Bronze Plan Enrollment Form
  4. 2023-24 Bronze Plan Payment Terms Agreement
  5. BC HMO Elements Bronze Plan Benefits Summary Plan Description
  6. BC HMO Elements Bronze Plan Summary of Benefits Coverage
  7. BC HMO Bronze Plan Elements Evidence of Coverage

Blue Cross Claim and Order Forms

  1. Express Scripts Home Delivery Order Form
  2. How to Use Mail Order Rx
  3. Prescription Drug Reimbursement/Claim Form
  4. Member Claim Form

Kaiser Permanente

  1. Kaiser Permanente Enrollment/Change Form
  2. Kaiser Permanente Summary Plan Description
  3. Kaiser Permanente Summary of Benefits Coverage
  4. Kaiser Permanente Evidence of Coverage
  5. Kaiser The Active & Fit Direct Program
  6. Kaiser Healthy Balance Weight Management Program No Cost
  7. Kaiser Center for Healthy Living Programs

Delta Dental HMO – DeltaCare USA

  1. DeltaCare USA - Enrollment/Change Form
  2. DeltaCare USA - Evidence of Coverage
  3. Delta Care USA – Enrollee Notice

Delta Dental PPO – Incentive Plan

  1. Delta Dental PPO Enrollment/Change Form
  2. Delta Dental PPO Evidence of Coverage
  3. Delta Dental PPO Highlights
  4. How Delta Dental Incentive Plan Works
  5. Delta Dental PPO – Enrollee Notice

Anthem EAP-Employee Assistance Plan

  1. EAP Service Summary
  2. EAP Brochure

Vision Service Plan (VSP) - No Enrollment Form Needed

  1. VSP Summary-All

Employer Paid Group Term Life Insurance

  1. LBCC Group Term Life Enrollment/Beneficiary Change Form
  2. Anthem Blue Cross Basic Life and AD&D Summary Plan Description
  3. Anthem Blue Cross AD&D Certificate Booklet
  4. UNUM Basic Life & AD&D Summary
  5. UNUM Life and AD&D Booklet

Optional & Voluntary Plans

  1. Savings & Retirement Plans through Schools First FCU
  2. Unum Instructions For Enrolling in Voluntary Products
  3. Unum Voluntary Short Term Disability
  4. Unum Long Term Disability
  5. Unum Voluntary Life and AD&D
  6. Unum Evidence of Insurability (medical questionnaire)
  7. Unum Voluntary Plans Beneficiary Form
  8. MetLife Beneficiary Form

Retiree Benefits Information

  1. Information for Existing Retirees
    Contact the Benefits Office at 562-938-4531 or 562-938-4465.

  2. Retiree Annual Notices
  3. LBCC Retiree Benefits Guide
  4. LBCC Post-65 Retirees Benefits Guide
  5. CCFA Full-Time Faculty Retiree Benefits Options FAQ
  6. Academic Administrators Retiree Benefits Options FAQ

  7. Retiring with CalSTRS (Start your retirement process with CalSTRS. Click on the link for instructions.)

  8. AFT and Classified Management Retiree Benefits Options FAQ

  9. Retiring with CalPERS (Start your retirement process from CalPERS. Click on the link for instructions.)

  10. 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.