In order to assist the District in ensuring that your eligible dependents are properly enrolled under your District-sponsored plan,
please read and follow the instructions below.
Complete this form, being sure to list all dependents you wish to have added. If necessary, attach an additional sheet
of paper to the form.
a. List birthdays and Social Security numbers for all dependents. Social Security numbers are mandatory. Social Security
numbers for newborns must be provided within two (2) months.
b. If your spouse/domestic partner is also a District employee/ retiree, please list his or her employee number.
Provide verification of dependent status for dependents as follows:
a. Spouse - attach a copy of your registered marriage certificate issued by the state. For new spouses, if a registered marriage
certificate is received within 45 days of the marriage date, spouse will be covered effective the date of the marriage.
b. Domestic Partner - complete Declaration of Domestic Partnership form (available from Benefits Administration) and
submit the required documentation as outlined in Section II of the Declaration form or submit a copy of your registration
with the State. If all of the required documentation is received by Benefits Administration by the 10
of the month,
coverage will be effective the first of the following month.
c. Natural children - attach a copy of official birth certificate for each child. For newborns, if verification of birth is received
within 30 days of birth (complimentary hospital birth certificate is acceptable), the newborn will be covered back to date
of birth. If submitted more than 30 days but less than 5 months, the newborn will be covered on the first of the month
after the verification was received. After a child is 5 months, an official birth certificate is required.
d. Stepchildren - for each child, attach a copy of the birth certificate and a copy of your registered marriage certificate
(issued by the state), and a copy of your latest income tax return showing the child’s dependent status.
e. Guardianship/Adopted children - attach a copy of the document verifying legal custody. If you submit verification of
guardianship/adoption within 30 days of the guardianship/adoption, coverage will begin on the date of
guardianship/adoption. If submitted after 30 days, coverage will begin on the first of the month after the verification was
f. If you are the legal guardian of a child, please attach a copy of the guardianship papers issued by the court.
g. Disabled dependent - must meet the disability standards of the plan and must be enrolled prior to age 19, or the dependent
child must be enrolled as a full time student prior to the disabling condition.
DEPENDENTS FOR WHOM THE REQUIRED DOCUMENTATION IS NOT RECEIVED WILL NOT BE COVERED
UNDER YOUR MEDICAL, DENTAL OR VISION PLAN(S) UNTIL THE APPROPRIATE DOCUMENTATION IS
EFFECTIVE DATE OF ADDITIONS:
Coverage will begin on the first day of the month following the receipt of the Health Benefits Enrollment form along with the
required verification. Example: If verification and Health Benefits Enrollment form is received by Benefits Administration on
January 1st, the dependent’s enrollment becomes effective February 1st.
Visit http://benefits.lausd.net for the Optional Life Insurance Brochure for payroll deducted supplemental life insurance.
TERMINATION OF COVERAGE:
Coverage will be terminated on the last day of the month in which the employee or the dependents became ineligible.
Complete and return this form (fax or email preferred) along with copies of the required documents to:
Fax: (213) 241-4247
Los Angeles Unified School District - Benefits Administration
P.O. Box 513307
Los Angeles, CA 90051-1307
Phone: (213) 241-4262