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Forms
Benefit Enrollment Forms - 2021
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CURRENT ENROLLMENT 2021
Open Enrollment begins
Oct. 1st and ends Nov. 1st
. All changes made will go into effect on
January 1st, 2021
.
If you have any questions, please contact Keri Wutzke at 619-390-2613, or email her at kwutzke@lsusd.net.
For Changes/Additions to your Medical Benefits, you can now
enroll online
through Nov. 1st, 2020.
Click the link below to create a new account.
Ares Member Portal
2021 Benefit Rates
2021 Summary of Benefits
2021 Benefits Summary.pdf
300.64 KB
(Last Modified on Tuesday at 3:21 PM)
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2021 LUSD Health Insurance Premiums-LTA
LTA 2021 Rate Flyer.pdf
448.31 KB
(Last Modified on Tuesday at 2:50 PM)
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2021 LUSD Health Insurance Premiums-CSEA
CSEA 2021 Rate Flyer.pdf
448.17 KB
(Last Modified on Tuesday at 2:51 PM)
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Medical Forms
VEBA Online
https://www.vebaonline.com/
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Universal Medical Enrollment Form
Medical Universal Enrollment Form.pdf
311.43 KB
(Last Modified on Tuesday at 2:56 PM)
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Alliance 1200 HMO Summary of Benefits
2020 Alliance 1200 HMO Summary of Benefits.pdf
132.1 KB
(Last Modified on Wednesday at 9:36 AM)
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Kaiser Summary of Benefits
2020 Kaiser HMO Summary of Benefits.pdf
125.22 KB
(Last Modified on Tuesday at 3:31 PM)
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United Health Care Net 1 Summary of Benefits
2020 UHC Net 1 HMO Summary of Benefits.pdf
142.85 KB
(Last Modified on Tuesday at 3:31 PM)
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United Health Care Net 2 Summary of Benefits
2020 UHC Net 2 HMO Summary of Benefits.pdf
131.66 KB
(Last Modified on Tuesday at 3:31 PM)
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Harmony 10 HMO Summary of Benefits
2020 Harmony 10 HMO Summary of Benefits.pdf
131.84 KB
(Last Modified on Tuesday at 3:32 PM)
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Vision Forms
VSP
https://www.vsp.com/
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VSP Summary of Benefits
VSP Premium Summary of Benefits.pdf
742.64 KB
(Last Modified on Tuesday at 2:59 PM)
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VSP Enrollment Form
VSP Enrollment Form.pdf
99.09 KB
(Last Modified on Tuesday at 2:58 PM)
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Waiver of Coverage
Waiver of Coverage
AFFORDABLE CARE ACT WAIVER OF COVERAGE.pdf
462.43 KB
(Last Modified on Tuesday at 2:58 PM)
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Dental Forms
Delta Dental PPO Summary of Benefits
2020 Delta PPO Summary of Benefits.pdf
400.39 KB
(Last Modified on Wednesday at 9:28 AM)
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Delta Care HMO Summary of Benefits
2020 DeltaCare DHMO Summary of Benefits.pdf
4.37 MB
(Last Modified on Wednesday at 9:27 AM)
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Delta Enrollment Form Dual Choice
Delta Enrollment Form Dual Choice.pdf
282.12 KB
(Last Modified on Tuesday at 3:06 PM)
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Life Insurance Forms
Hartford Basic Life Enrollment Form
The Hartford Basic Life Enrollment Form.pdf
22.74 KB
(Last Modified on Tuesday at 3:51 PM)
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MetLife Legal
MetLife Legal Plan Enrollment Form
2020 MetLife Legal Plan Enrollment Form.pdf
124.18 KB
(Last Modified on Tuesday at 3:57 PM)
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MetLife Legal Plan Summary of Benefits
2020 MetLife Legal Plan Description.pdf
59.85 KB
(Last Modified on Wednesday at 9:26 AM)
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