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Get Ca Lausd Health Benefits Enrollment Form 2008-2024

SINGLE MARRIED INITIALS MI ZIP PHONE NUMBER SOCIAL SECURITY NUMBER DATE PROCESSED BARGAINING UNIT I HAVE REVIEWED THE HEALTH PLAN OPTIONS AVAILABLE. PLEASE ENROLL ME IN THE PLAN(S) CHECKED BELOW. Coverage under the District s health care and life insurance plans begin the first day of the month following the date your properly completed Enrollment Form is received by the Health Benefits Administration, provided you are actively at work. CHECK (/) ONLY ONE PLAN NAME MEDICAL 0070 M.

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