Cal pers forms pers hbd 12 2002-2025

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The document is a Health Benefits Plan Enrollment Form (HBD-12) for the California Public Employees’ Retirement System (CalPERS). It outlines the process for active employees to enroll, change, or cancel their health benefits coverage. The form requires personal information such as Social Security numbers, marital status, and details about dependents. It also includes instructions for both members and employers on how to complete the form and emphasizes the importance of providing accurate information for eligibility verification.

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

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (81 Votes)
2013	4.3 Satisfied (98 Votes)
2010	4.9 Satisfied (51 Votes)
2002	4.4 Satisfied (318 Votes)

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What is HBD 12 form?

Health Benefits Plan Enrollment Form for Active Employees (HBD-12) (PDF)

What is the benefit enrollment program?

Benefits enrollment is a designated time when eligible employees may elect to participate in employer-sponsored benefits for the upcoming plan year. New employees can elect benefits as allowed by the plan when first hired, while current employees can review and modify their selections from the previous plan year.

What is HBD 12?

Health Benefits Plan Enrollment for Active Employees (HBD-12) Instructions. Page 1. State of California. California Public Employees Retirement System. .calpers.ca.gov.

What is the purpose of a health and dental enrollment form?

This enrollment form allows individuals to apply for group health and dental coverage. Its designed for employees to provide necessary personal information, dependent details, and coverage choices.

What is the purpose of an enrollment form?

An enrollment form is a type of form used to collect information from individuals who are registering for a service, program, or event. The purpose of an enrollment form is to gather the necessary data to enroll the individual and ensure that they meet the eligibility criteria for the service or program.