Get Ca Calpers Hbd-12 2002

The CA CalPERS HBD-12 is a crucial form for members seeking to enroll in health benefits. Completing this form accurately is essential for ensuring that you receive the appropriate health benefits coverage in a timely manner.

Follow the steps to accurately complete the CA CalPERS HBD-12 online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by selecting the type of action you are taking. Check one of the options in Box 1: A for new enrollment, B for change of coverage, C for canceling all coverage.
3. In Box 2, enter your Social Security number. If applicable, also provide the Social Security number of your spouse or domestic partner.
4. Fill in Box 4A with your full name as shown on your appointment document along with your mailing address including City, State, and ZIP Code in Box 4B.
5. Check the appropriate box in Box 5 if you are a permanent intermittent employee.
6. In Boxes 6 and 7, indicate your sex by checking the corresponding box and your marital status by selecting Yes or No.
7. Refer to the Health Program Guide or other resources to enter the correct plan code and health plan name in Boxes 8 and 9, respectively.
8. Enter the gross premium amount in Box 10, and identify your primary care physician or medical group in Box 11.
9. If changing plans, fill out Boxes 12 and 13 with the prior plan code and health plan.
10. In Box 14, enter the appropriate code for the permitting event, and specify the date in Box 15.
11. Write the effective date of your enrollment or change in Box 16.
12. In Box 17 and/or 18, list all family members to be enrolled, using the action codes A for additions and D for deletions.
13. Check one of the options in Box 19 to indicate your enrollment wishes, whether to enroll, cancel, or decline.
14. Sign and date the form in Boxes 20 and 21, respectively, to authorize deductions and verify eligibility.
15. Complete Boxes 22-27 if applicable, following the instructions pertaining to deduction codes and action types.
16. Enter agency name, codes, and the signature of the Health Benefits Officer as required in Boxes 28-32.
17. Finally, provide any additional information in Box 35 and double-check all entries before finalizing.
18. Once all information is completed, save changes, download the form, print it, or share it as necessary.

Complete the CA CalPERS HBD-12 online now to ensure your health benefits enrollment is processed without delay.