Form 3460 CA PMD - countyofsb-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Primary Enrollee Information' section. Enter your Social Security Number, First Name, Last Name, and Mailing Address. Ensure all details are accurate for processing.
3. Next, indicate any changes such as Address Change, Add/Delete Dependent, or Terminate Enrollee Coverage by checking the appropriate boxes.
4. In the 'Dependent Information' section, provide details for each dependent you wish to enroll or terminate. Include their names, Social Security Numbers, and Dates of Birth.
5. Review your entries carefully. Once satisfied, sign and date the form at the bottom to authorize any necessary payroll deductions.

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