ACTIVE EMPLOYEES

The JLMBC is pleased to offer the following quality health benefit plans to eligible employees and their dependents, beginning January 1, 2010:

You can find the new CalPERS Health Plan Enrollment form here.

If you have any questions, please call the LACCD Benefits Call Center at (888) 428-2980. You can also refer to the list of important phone numbers and addresses.

Information to Help You During Open Enrollment

2010 Highlights Booklet
Active Employee CalPERS Video
Annual Enrollment Notice 2010
Open Enrollment Calendar
Open Enrollment Online - How-To Guide (2009 process continues for 2010)
Flexible Spending Accounts (summary of both the FSA and the HRA)
Important Contact Information
CalPERS 2010 Health Benefit Summary
	A side-by-side comparison of all CalPERS health plans
CalPERS 2010 Health Program Guide
	A complete information guide to your CalPERS health benefits
CalPERS 2010 Your Health Care, Your Choices
	Tips and tools for making important decisions about your health care
2010 Dental Vision Plan Summary
Benefit Highlights for Delta Dental PPO
Delta Dental PPO- Using Your Plan
SafeGuard Plan Comparison Summary (2009 benefits continue for 2010)

Forms and Information You May Need

Information
	Kaiser for CalPERS Members flyer
	General information about Flexible Spending Accounts
	Wells Fargo HRA
	2010 Summary of Rights
	2010 CalPERS Premium Rates	New!
General Forms
	2009 Enrollment/Change Form for Active Employees
	2010 Dental and Vision Enrollment/Change Form
	2010 CalPERS Health Plan Enrollment Form (medical plans only)
	Blue Shield - Request for Continuity of Care
	Blue Shield - Declaration of Disability for Overage Dependent Child
	Blue Shield - International Claim Form
	Blue Shield - Rx Claim Form
	Blue Shield - Statement of Claim Form
	Blue Shield - Disabled Dependent Form
	Kaiser - Claim for Emergency Services Form
	VSP Out of Network Reimbursement Form
	Certification of Video Display Terminal Use
Term Life Insurance Forms and Information
	Employee Life Rate Schedule
	Spouse Life Rate Schedule
	MetLife Application
	MetLife Beneficiary Designation Form
Domestic Partner Forms and Brochure
	Program Summary
	Affidavit
	Tax Form
	Terminating a California Registered Domestic Partnership
	Declaration of Termination of Domestic Partnership (form)

last updated 10/19/09

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