EMPLOYEE BENEFIT DOCUMENTS AND FORMS
- Health Plan Tax Dependent Form
- Affidavit of Domestic Partnership
- Catastrophic Illness Leave Donation Program Application (Revised 2010)
- Domestic Partnership Information sheet (revised 10/13/11)
- Termination of Domestic Partnership Form (Revised 10/13/11).
- Verification of Dependent Status Form (Revised October 2010)
This form is only to be used by the parent of an enrolled grandchild. - 2012 Cash In Lieu Affidavit for Civilian Employees
- FSA Eligible Health Care Expenses - Spanish
- Important Information About Your COBRA Continuation Rights (Revised 11/08/10)
- Family Status Change Bulletins
- California State Law AB 25 - Domestic Partner Rights
- Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- Important Information for Active, Medicare-Eligible Employees (Created 05/03/11)
- Flex Benefits FAQs for Employees thinking about Retirement
- Anthem Blue Cross 2011 Enrollment Kits
- Anthem Claim Form (Current as of 09/14/09)
- Away From Home / Guest Membership Brochure (Current as of 09/14/09)
- Blue View Vision flyer (Revised 03/05/12)
- Guest Membership Flyer (Current as of 09/14/09)
- HIPAA Individual Authorization Form (09/29/08)
- HMO Benefits while you Travel (Current as of 09/14/09)
- Anthem Blue Cross Provider Directories (Revised date 10/2010)
- International Claim Form (Current as of 09/14/09)
- Online Services (Current as of 09/14/09)
- PPO Benefits while you Travel (Current as of 09/14/09)
- Anthem / Express Scripts Prescription Drug Claim Form
- Special Offers for Anthem members (Current as of 09/14/09)
- 2012 Anthem Blue Cross PPO
- 2012 Anthem BlueCard
- 2012 Anthem Blue Cross HMO
- 2012 Anthem BlueView Vision
- 07-01-2011 City PPO RX Benefits
- 07-01-2011 City HMO RX Benefits
- 2012 Kaiser Permanente EOC for Civilian Employees
- Kaiser Disabled Dependent Application
- Kaiser Hospital Update for Kern County (effective 03/31/09)
- Kaiser Visiting Member Program
- Choosing Between a PPO and HMO Dental Plan (Revised March 2006)
- Delta Preferred Option Evidence of Coverage (EOC) (Effective 01-01-2011)
- Delta Preventive Evidence of Coverage (EOC) (Effective 01-01-2011)
- DeltaCare USA DHMO Evidence of Coverage (EOC) (Effective 01-01-2011)
- How to Get Dental Care When You're Outside the U.S. (Revised March 2007)
- Information About Your Dental Coverage Options (Flex Dental or EAA) (Revised September 2008)
- EZ Receipts mobile app
- Flexible Spending Accounts Overview
- Flexible Spending Account Enrollment Form
- FSA Eligible Health Care Expenses - English
- How much will you save this year?
- Spending Account Interactive Claim Form
- Flexible Spending Account Claim Form (Healthcare Account)
- Flexible Spending Account Claim Form (Dependent Care Account)
- Accelerated Benefit Provisions
- Privacy Notice
- True Portability & Conversion Questions and Answers
- 2011 Group Life Insurance Certificate & Policy
- Checklist for Surviving Family Members (Revised 09/02/10)
- Imputed Income Fact Sheet (Revised 12/28/06)
- Imputed Income Formula (Effective 1/1/06)
- Evidence of Insurability (Medical History Statement) for Standard Insurance
- 2011 Group Long Term Disability Certificate & Policy
- 2011 Group Short Term Disability Certificate & Policy
- Benefit Protection Plan Frequently Asked Questions (Revised 12/11/07)
- FICA Withholding & Taxation of Disability Benefits (Revised December 2006)
- Evidence of Insurability (Medical History Statement) for Standard Insurance
- Overview of Benefit Protection Plan (Revised 01/17/08)
- Pregnancy Claim Guidelines (Revised August 2006)
- 2009 Maternity and Disability Guidelines (Revised August 2008)
- Disability Claim Package (Revised November 2007)
(Note: Standard Insurance does not consider your claim complete until it receives documentation from the Employee Benefits Division along with the employee and treating physician statements. Please call (213) 978-1655 for more information.)
Forms and Documents
This form can be used to help you determine whether a same-sex spouse, domestic partner or that person's children are considered your health plan tax dependent and therefore, not subject to the imputed income associated with the cost of medical insurance for that individual. It can also be used to help you determine whether the out-of-pocket medical, dental and vision expenses of a household member are eligible for reimbursement under the Healthcare Flexible Spending Account. Please contact the Internal Revenue Service (IRS) at 1-800-829-1040 or your tax advisor for guidance. It is imperative to understand that the City of Los Angeles and any of its affected contractors assume no responsibility for your determination that an individual is or is not a health plan tax dependent. You are subject to all tax implications/consequences based upon your decision and the form that you submit to the City of Los Angeles and any of its affected contractors.
2012 Civilian Flex Benefits
General Benefits Information
Medical Coverage
Anthem Blue Cross
Kaiser
Dental Coverage
Dependent Care Reimbursement Account
HealthCare Flexible Spending Account
Life Insurance
Disabililty Coverage
Accidental Death & Dismemberment Coverage
EAP/MHN Brown Bag Workshops
an equal opportunity employer