Cal pers forms pers hbd 12 2002-2026

1. Click ‘Get Form’ to open the cal pers forms pers hbd 12 2002 in the editor.
2. In Box 1, select the type of action: New enrollment, Change of coverage, or Cancel all coverage.
3. Enter your Social Security Number in Box 2 and your spouse’s SSN in Box 3 if applicable.
4. Fill out Box 4A with your name and mailing address. If different, provide the residence ZIP code in Box 4B.
5. Indicate your employment status as Permanent Intermittent in Box 5 if applicable.
6. Select your sex and marital status in Boxes 6 and 7 respectively.
7. Complete Boxes 8 and 9 with the Plan Code and Health Plan name from the Health Program Guide.
8. Input the gross premium amount in Box 10 and designate a primary care physician in Box 11.
9. For any changes or cancellations, fill out Boxes 12 and 13 accordingly.
10. List all family members to be enrolled in Boxes 17 and/or 18 using appropriate Action Codes for additions or deletions.
11. Sign and date the form in Boxes 20 and 21 to authorize deductions for premiums.

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