CalPers+Medical+enrollment+and+change+form by xuyuzhu

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									Cal-PERS                                     NOTE: Your employee premium portion can be taken out on a pre-tax basis by
HEALTH BENEFIT PLAN                          signing up through American Fidelity…..If you are cancelling your medical and
ENROLLMENT FORM HBD-12                       had the premium taken out pre-tax and if you decide re-enroll in medical at a later
                                             date then you MUST re-enroll in the pre-tax premium option during open enrollment time!!!!!
        Type of Action                             Social Security # of Employee                              SEX                          Married

            NEW enrollment                                                                        Male                          Yes
            CHANGE of enrollment                                                                Female                           No
            CANCEL all coverage

First and Last Name

Mailing Address

City, State, Zip
Home Telephone#

                     List ALL Person(s) to be added or enrolled
  Action     even if already enrolled & put "A" in action code for those    If deleting an enrollee, put "D" in the action code column
  Code                           being newly added                           next to their name and list all others to remain enrolled
                   (First)           (MI)              (Last)              Date of Birth Family Relationship          Social Security#

                                                                                                       Self




           Plan Code                           Name of Current/Changed to Health Plan                         Gross Premium


 Name of Prior Health Plan                   Primary Care Physician/Medical Grp                               Employee Payroll Deduction
                                             (This is only necessary when choosing Blue Shield HMO)
***Any info you don't know, just leave blank and we will complete for you.

                                          EFFECTIVE DATE OF ACTION
        CHECK ONE:
          I elect to enroll in (or change to) a Health Benefits Plan as shown above and authorize deductions to be
          made from my salary or retirement allowance to cover my share of the cost of enrollment as it is now or
          as it may be in the future. I also certify that the names of all dependents listed above are eligible
          family members as defined in the Public Employees' Medical and Hospital Care Act.
          I elect to CANCEL the Health Benefits Plan as shown above.

            I am waiving medical health insurance because I have coverage through another source (you must provide
            proof of other insurance)


                                Employee Signature                                                                          Date

Date received into Benefits Office                                         YOU MAY FAX THIS FORM TO 661-294-3585

								
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