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:

  • The January 2019 roll-over to tiered coverage for all Participants and their Dependents. THIS IS DUE DECEMBER 15, 2018.
  • Changes to your selected Primary Care Physician (PCP) for HMO Participants and their Dependents. These changes can be made anytime.
  • 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.

EMPLOYEE INFORMATION

MEDICAL PLANS (SELECT ONE)

Verify your Income Tier here.

INCOME TIERS

  • Tier One: The Medical Plan provided is the California Classic HMO
  • Tier Two: The Medical Plan provided is the California Classic HMO with an option to “Buy Up” to the Classic Premier PPO. Click here for Buy Up prices.
  • Tier Three: The Medical Plan provided is the Classic Premier PPO with an option to Opt Out and choose the California Classic HMO. Click here for more details.

INDICATE YOUR PROVIDED MEDICAL PLAN