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- Click ‘Get Form’ to open the HBD-12 in the editor.
- Begin with SECTION A: Applicant Information. Fill in your Employee Name, CalPERS ID or Social Security Number, Date of Birth, and Residence Address. Ensure all details are accurate.
- In SECTION B: Type of Action, select the appropriate action you wish to take regarding your health plan by checking the corresponding box.
- Proceed to SECTION C: Type of Permitting Event. Indicate the event that applies to your situation and provide the relevant dates.
- SECTION D requires you to list yourself and any dependents. Fill in their names, relationships, genders, and dates of birth accurately.
- In SECTION E: Enrollment, review the information provided and check the box indicating your decision to enroll or decline coverage.
- Finally, sign and date the form at the bottom of SECTION E before submitting it through our platform for processing.
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