Freelance Employee Enrollment and Change Form (California Participants)

Please fill out the form below to submit to BeneSys Administrators.

WHO COMPLETES THIS FORM

• ALL freelancers

USE THIS FORM FOR:

• Tier changes upon the annual renewal for Participants and their Dependents.
• Changes, Additions, or Subtractions of Dependents that can only take place during the annual open enrollment which coincides with the Participant’s annual renewal.
• Adding Dependents during non-enrollments periods within 30 days of a ‘Qualifying Event’ such as a marriage, birth, adoption, or cancellation of a spouse’s prior coverage. Supporting documentation (marriage, birth, or adoption certificates or proof of prior coverage) must be submitted to BeneSys Administrators at staff@PHBPBenefits.org.
• Newly eligible participants.
• Adding or changing a life insurance beneficiary.

EMPLOYEE INFORMATION

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

MEDICAL PLANS (SELECT ONE)