20-21 Health & Welfare Benefits - New Employee Enrollment

H&W Enrollment Retirees

22-23 School Year
Name*

First NameLast Name
New HireRetiree
Last 6 Digits of Social Security #*
E-mail (District)*

Confirmation Emailexample@example.com
E-mail (Personal)*

Confirmation Emailexample@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Cell Phone*
Hire or Retirement Date*

MonthDayYear
Date
Benefit Start*
District CAP Start*
Bargaining Unit*
Work Calendar*
Employee Status*
Will you be covering Dependents?*

Yes, Medical, Dental and VisionYes, Dental and Vision OnlyNo, I will not be covering any dependentsOther
Dependents to be Covered*

SpouseDomestic PartnerChild(ren)Step-Child(ren)None
21-22 Plan Selections

July 2022 - September 2022
Click Here to Open the Medical Plan Comparisons in a New Tab

Click Here to Open the Dental Plan Comparisons in a New Tab
21-22 Medical Plan *
Active
21-22 Medical Plan R*
Retiree
21-22 Medical Rate
Active
21-22 Medical Rate R
Retiree
21-22 Dental Plan*
21-22 Dental Rate
21-22 Vision Plan*
Same Rate Applies to all Tiers
21-22 Vision Rate
21-22 Life Insurance *
21-22 District CAP*
FTE*
FTE in Decimal
21-22 CAP $
Summer Cost
Summer Cost (Monthly)
21-22 Total Employee Cost
(Monthly July-September)
No Cost to Employee
22-23 Plan Selections

October 2022 - June 2023
Yes, I'd like the same plans as I chose for 21-22No, I'd like to choose a different plan for 22-23 beginning October 1st.
*Please note that 22-23 are estimated rates and are subject to change
22-23 Medical Plan *
Active
22-23 Medical Plan R*
Retiree
22-23 Medical Rate
Active
22-23 Medical Rate R
Retiree
22-23 Dental Plan*
22-23 Dental Rate
22-23 Vision Plan*
Same Rate Applies to all Tiers
22-23 Vision Rate
22-23 Life Insurance *
22-23 District CAP*
22-23 FTE*
FTE in Decimal
22-23 CAP $
Summer Cost (Monthly)
22-23 Total Employee Cost
(Monthly October - September)
Date*

MonthDayYear
Signature*
Comments / Notes
Once you click the submit button you will need to click on the link to go to MyCVT to enroll in your medical plan. If adding dependents, you will need scanned copies of your birth and/or marriage certificates or domestic partner affidavit.

You will receive an email confirming your above selections. The following forms must be downloaded, completed, and returned to the Live Oak District Office to complete enrollment for dental/vision and life insurance. Note: The Domestic Partner Affidavit only needs to be filled out if you are covering a domestic partner.

All Forms are also available for download on our website: LOSD Benefits

If you have any questions, please email losdbenefits@losd.ca and we will get back to you as soon as possible.
Dental/Vision
Life Ins Enrollment
Domestic Partner Affidavit
Should be Empty:

H&W Enrollment Retirees

21-22 Plan Selections

22-23 Plan Selections