HBD-12: CalPERS Health Benefits Plan Enrollment

Form HBD-12 PDF Details

In Section E, to enroll, carefully review the information in this section and check the box.

If you decline: if you choose to enroll at a later date, you must wait at least 90 days after you request enrollment or until the next Open Enrollment (OE) period.

Lost coverage: if you or your dependents involuntarily lose other health insurance coverage, you may request enrollment within 60 days from the date of lost coverage.

Relationship: S - Spouse, DP - Domestic Partner, NC - Natural Child, SC - Step Child, AC - Adopted Child, DPC - Domestic Partner Child, PCR - Parent Child Relationship.

Social Security number: the CalPERS health program requires each enrollee's Social Security number for identification purposes and to verify eligibility for benefits.