Get Pers-hbd-12 (rev

Filling out the PERS-HBD-12 (Rev) form can seem daunting, but with clear guidance, you can complete it easily and efficiently. This guide provides you with step-by-step instructions for each section of the form to ensure you have all the necessary information for successful enrollment in the health benefits plan.

Follow the steps to accurately complete the PERS-HBD-12 (Rev) form online.

1. Use the ‘Get Form’ button to access the PERS-HBD-12 (Rev) form. Once you have the form, open it in your preferred editor.
2. Begin with the 'Type of Action' section. Check one of the boxes indicating whether you are enrolling for the first time, changing coverage, or canceling your current coverage.
3. Enter your social security number in the designated field, ensuring accuracy to avoid any processing delays.
4. Input your name by filling in the first name, middle initial, and last name fields.
5. Provide your daytime phone number, residence address, and ZIP code in the respective fields, using correct formatting.
6. List all individuals to be enrolled, including yourself, along with their social security numbers, dates of birth, and relationships to you.
7. Select your gender and specify marital status by checking the appropriate boxes.
8. Complete the 'Health Plan' section by filling in the plan code and health plan name, as well as any gross premiums and primary care physician information.
9. Review the 'Reason Code' and 'Permitting Event Date' sections, filling them out as necessary based on your situation.
10. In the declaration section, carefully read the statement and select whether you elect to enroll, change, or cancel your health benefits. Provide your signature and the date signed.
11. Finish by following any remaining instructions, ensuring all required sections are completed, and save your changes. You can download, print, or share the completed form as needed.

Begin completing your PERS-HBD-12 (Rev) form online today to ensure your health benefits enrollment is processed smoothly.