Health Benefit Plan Enrollment Form - California
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2
3California Public Employees' Retirement System
P.O. Box 942715
Sacramento, CA 94229-2715
HEALTH BENEFIT PLAN
ENROLLMENT FORM
DO NOT SEND MEDICAL
CalPERS
CLAIMS TO THIS ADDRESS
USE ONLY - DOCUMENT REFERENCE NUMBER
PERS-HBD-12 (Rev. 6/13)
PLEASE TYPE
G
2. SOCIAL SECURITY NUMBER
1. TYPE OF ACTION
Family
DATE OF
E
LIST ALL PERSONS (including self)
A
C
N
C
(Check One)
Relation-
BIRTH
TO BE ENROLLED IN:
T
O
D
C
I
ship
D
O
E
O
E
N
R
D
a. NEW enrollment
3. SPOUSE/DOMESTIC PARTNER'S SOCIAL SECURITY
E
17. BASIC PLAN
Mo. Day Yr.
M
F
NUMBER
b. CHANGE of coverage
(FIRST)
(LAST)
(MI)
SELF
c. CANCEL all coverage
4A.
SSN
Name
(FIRST)
(MI)
(LAST)
(MI)
(FIRST)
(LAST)
Mailing
(LAST)
Address
City,
Daytime Phone
Evening Phone
SSN
State, ZIP
(FIRST)
(MI)
(LAST)
4B. RESIDENCE ZIP CODE
(If different from 4A)
Please check if
5.
6. GENDER
7. MARRIED
SSN
Permanent Intermittent
Male
Yes
Employee (applies to active
(FIRST)
(LAST)
(MI)
Female
No
State employees only)
8. PLAN CODE
9. NAME OF HEALTH PLAN
SSN
10. GROSS PREMIUM
11. PRIMARY CARE PHYSICIAN/MEDICAL GROUP
$
18. SUPPLEMENTAL PLAN
Relation-
12. PRIOR PLAN CODE
13. PRIOR HEALTH PLAN
DATE OF BIRTH
C
A
O
C
C
ship
(FIRST)
(MI)
(LAST)
D
T
Mo. Day Yr.
O
E
I
D
O
15. Permitting Event Date 16. EFFECTIVE DATE
14. Reason Code
E
N
Mo.
Day
Yr.
Mo.
Day
Yr.
01
19. CHECK ONE
I DO NOT elect to enroll in a Health Benefits Plan under the Public Employees' Medical and Hospital Care Act.
I elect to ENROLL IN (OR CHANGE TO) a Health Benefits Plan as shown in Items 8 and 9 above and authorize deductions to be made from my
salary or retirement allowance to cover my share of the cost of enrollment as it is now or as it may be in the future. I also certify that the names of
all dependents listed above in items 17 and/or 18 are eligible family members as defined in the Public Employees' Medical and Hospital Care Act.
I elect to CANCEL the Health Benefits Plan as shown in items 12 and 13 above.
20. EMPLOYEE OR ANNUITANT'S SIGNATURE (see privacy information on reverse of employee copy)
21. DATE SIGNED
Mo.
Day
Year
TELEPHONE NUMBER (
)
PLEASE REFER TO THE HEALTH BENEFITS PROCEDURE MANUAL FOR COMPLETION OF ITEMS 22-27
27. BARGAINING UNIT
22. DEDUCTION
24. PAY PERIOD
25. PARTY CODE
26. EMPLOYEE
New
23.Type of
1.
Year
DESIGNATION
Month
PLAN CODE
Cancel
action
2.
Change
(Check One)
3.
31. UNIT CODE
30. AGENCY CODE
28. AGENCY NAME (or Retirement System)
29. PAYROLL OFFICE CODE
32. I hereby certify under penalty of perjury as follows:
SIGNATURE OF HEALTH BENEFITS OFFICER
33. Date received in
employing office
That I am a duly appointed, qualified and acting officer
Day
Mo.
Day
Year
34. PHONE NUMBER
of the above named agency, and that payment by the
agency as provided by Sections 22870-22905 of the
Government Code is hereby approved. Final determina-
tion of eligibility for the enrollment action specified will
35. REMARKS
be made by the Board of Administration, Public
___________ of__________ Forms
Employees' Retirement System, in accordance with the
WHITE – HB PINK – Agency BLUE - Employee
Public Employees' Medical and Hospital Care Act.
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