Lompoc Unified School District

Insurance: Guides

• 2024-2025 VSP VISION BENEFITS SUMMARY
• 2024-2025 Benefits Guide Classified
• 2024-2025 Benefits Guide Certificated - Management - Confidential
   

Insurance: Enrollment Forms

• SISC III MEMBERSHIP CHANGE FORM

Use this form to change, add and/or delete dependents on your medical insurance only.

• To add a dependent, you must provide a marriage certificate, birth certificate or adoption certificate.
• To remove a dependent you must provide a divorce decree, death certificate or proof of other insurance.
• You must provide a new Social Security card to change name(s) or Social Security number(s).

• MEMBERSHIP ENROLLMENT FORM
   
  • Use this form to make changes to your Vision Service Plan.
  • No other documentation is required.
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• Delta Dental Enrollment​​​​​​​

• Use this form to make changes to your Dental plan.
• Dental insurance enrollment is only available when you are hired, have a qualifying event or during Dental open enrollment.Dental open enrollment is only available every 5 years.
• The next Dental open enrollment is in June 2025.No additional documentation is required.

Insurance: Frequently Used Websites

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403b Compare

403b Compare - Website

Aflac

Aflac - Website

American Fidelity

American Fidelity - Website

American Fidelity Assurance Company 1-800-325-0654

Anthem Blue Cross

Anthem Blue Cross - Website

Anthem Blue Cross 1-800-322-5709

Delta Dental

Delta Dental - Website

Delta Dental 1-888-335-8227

TDS Group (403b plans)

The TDS Group - Tax Sheltered Annuities - 403b Plans

1-866-446-1072, opt 4

VSP - Vision Service Plan

VSP - Vision Service Plan 1-800-877-7195

Retiree Cancellation Request form

Use this form to cancel one or all District insurance plans. If you are keeping your coverage but cancelling a dependent's health insurance, you must use the SISC membership change form. Self-Injured Schools of California  under Forms & Notices

Retiree Insurance Cancellation form

Use this form to cancel one or all insurance plans. If you are keeping your coverage but dropping a dependent's health insurance, you must use the SISC membership change form found at  Self-Injured Schools of California under Forms & Notices.

• CalPERS - Classified
• CalSTRS - Certificated
• SISC Defined Benefit Plan

Payout/Roll-Over of Vacation Balance

Per the Classified Bargaining Unit Contract Article 8.5, "the equivalent of up to one (1) year’s earned vacation may be accumulated and carried over for one (1) fiscal year to the next fiscal year. Any balance in excess of that amount, as of June 30, will be paid in July." As this is paid July 10 on the supplemental, it is paid out as a physical check.

Article 8.5.1 expands to allow a carry-over perior which "may be extended six (6) months (December 31) with prior permission of the immediate management supervisor certifying the employee will use the excess vacation before December 31."

If not used by December 31st, vacation accrual will cease until the excess has been used.

If Payroll does not receive a response by June 7th, accrued vacation balance (not in excess of one year) will automatically carry over to the next school year and any excess will be paid out--You do not need to return this form to have your excess paid out.

403b Enrollment/Cancellation/Change Form

Enroll, cancel or change the amount of your 403b plan. This form MUST BE in the Payroll Office by the 15th of the month in order to be effective on that month's payroll check.

• All requests MUST be received in the Payroll office by the 15th of the month prior to effective date.
• It takes two pay periods for Direct Deposit to begin; therefore, the first pay period following submission will be a check which will be mailed out to you unless you have made other arrangements with payroll.
• You may distribute your net pay to 3 different banking institutions.
• Submit the Direct Deposit application and a direct deposit form from your bank (or cancelled check) which includes your name, routing number, and account number to LUSD Payroll; DO NOT SEND COMPLETED FORMS TO THE COUNTY OFFICE OF EDUCATION.
• A Deposit Format Letter is required for deposits to Coast Hills Credit Union.

Direct Deposit Enrollment/Cancellation Form

• All requests MUST be received in the Payroll office by the 15th of the month prior to effective date.
• It takes two pay periods for Direct Deposit to begin; therefore, the first pay period following submission will be a check which will be mailed out to you unless you have made other arrangements with payroll.
• You may distribute your net pay to 3 different banking institutions.
• Submit the Direct Deposit application and a direct deposit form from your bank (or cancelled check) which includes your name, routing number, and account number to LUSD Payroll; DO NOT SEND COMPLETED FORMS TO THE COUNTY OFFICE OF EDUCATION.
• A Deposit Format Letter is required for deposits to Coast Hills Credit Union.

Authorization for Payroll Direct Deposit

Salary Amendment Agreement_403b_Roth_CA_v3doc_LUSDistrict_1

Working Out Of Class (WoC) Timesheet

IMPORTANT – PAY STUB INFORMATION FOR EMPLOYEES WITH DIRECT DEPOSIT

INSTRUCTIONS for Completion of the Timesheet

Timesheet Overtime Additional Time

Non Duty Days VAC Payout 2016

Summer Savings Form

FOUR DAY WORK WEEK REQUEST

Employee's Withholding Allowance Certificate

CLASSIFIED PERSONNEL ABSENCE REPORT

CERTIFICATED PERSONNEL ABSENCE REPORT

Sick Leave Request Form

Employee’s Withholding Certificate

PAYOUT/ROLL-OVER OF VACATION BALANCE

ONLINE PORTAL OVERVIEW

2024-2025 Payroll Calendar

SIPE Employee Incident Report