Staff Employee Enrollment and Change Form

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

Enrolling and continuing enrollment of all Staff Employees and their Dependents in the PHBP Health Plan.
Changes, Additions, or Subtractions of Dependents that can only take place during the annual open enrollment (in December for a January 1 effective date).
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 (due to involuntary reasons). Supporting documentation (marriage, birth, or adoption certificates or proof of prior coverage) must be submitted to BeneSys Administrators at staff@PHBPBenefits.org.
For newly hired Staff Employees, coverage begins on the first day of the month following 30 days from the employee’s date of hire.
For Production Companies that join the PHBP for the first time, coverage of Staff Employees begins on the date indicated by the PHBP on the Production Company’s Staff Coverage Election Form.
For Freelance Employees already covered by the PHBP, who move into a Staff Employee position, coverage begins on the first day of the month following the start of your staff employment.

Employer Name

Hire Date

Coverage Effective Date

First Name

Middle Initial

Last Name

Maiden Name

Address

City

State

Zip Code

Marital Status

Single

Married

Divorced

Home Phone

Business Phone

Language Preference

Medical Plan

California Classic HMO (California Only)

PHBP HDHP + Health Savings Account

PHBP Classic Plus PPO

PHBP Classic Premier PPO