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Cal pers forms pers hbd 12 2002-2026
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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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