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Documents
127
![Form HBD-12 "Health Benefits Plan Enrollment for Active Employees" - California](https://data.templateroller.com/pdf_docs_html/2075/20759/2075912/form-hbd-12-health-benefits-plan-enrollment-for-active-employees-california.png "Form HBD-12 "Health Benefits Plan Enrollment for Active Employees" - California")
Form HBD-12 "Health Benefits Plan Enrollment for Active Employees" - California
Size: 371 KB
3 pages
![Form HBD-30 "Health Benefits Plan Enrollment for Retirees and Survivors" - California](https://data.templateroller.com/pdf_docs_html/2085/20855/2085592/form-hbd-30-health-benefits-plan-enrollment-for-retirees-and-survivors-california.png "Form HBD-30 "Health Benefits Plan Enrollment for Retirees and Survivors" - California")
![Form PERS-BSD-35 "Authorization to Disclose Protected Health Information" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063473/form-pers-bsd-35-authorization-to-disclose-protected-health-information-california.png "Form PERS-BSD-35 "Authorization to Disclose Protected Health Information" - California")
![Form PERS-BSD-92 "Workers' Compensation Carrier Request" - California](https://data.templateroller.com/pdf_docs_html/2063/20635/2063500/form-pers-bsd-92-workers-compensation-carrier-request-california.png "Form PERS-BSD-92 "Workers' Compensation Carrier Request" - California")
![Form PERS-HBD-85 "Group Continuation Coverage (Cobra)" - California](https://data.templateroller.com/pdf_docs_html/2022/20229/2022956/form-pers-hbd-85-group-continuation-coverage-cobra-california.png "Form PERS-HBD-85 "Group Continuation Coverage (Cobra)" - California")
![Form HBD-34 "Medical Report for the CalPERS Disabled Dependent Benefit" - California](https://data.templateroller.com/pdf_docs_html/1788/17882/1788257/form-hbd-34-medical-report-the-calpers-disabled-dependent-benefit-california.png "Form HBD-34 "Medical Report for the CalPERS Disabled Dependent Benefit" - California")
Form HBD-34 "Medical Report for the CalPERS Disabled Dependent Benefit" - California
Size: 146 KB
3 pages
![Form HBD-98 "Member Questionnaire for the CalPERS Disabled Dependent Health Benefit" - California](https://data.templateroller.com/pdf_docs_html/1788/17885/1788569/form-hbd-98-member-questionnaire-the-calpers-disabled-dependent-health-benefit-california.png "Form HBD-98 "Member Questionnaire for the CalPERS Disabled Dependent Health Benefit" - California")
![Form PERS-HBD-21 "Direct Payment Authorization" - California](https://data.templateroller.com/pdf_docs_html/1788/17881/1788178/form-pers-hbd-21-direct-payment-authorization-california.png "Form PERS-HBD-21 "Direct Payment Authorization" - California")
![Form HBD-40 "Affidavit of Parent-Child Relationship" - California](https://data.templateroller.com/pdf_docs_html/1788/17881/1788131/form-hbd-40-affidavit-parent-child-relationship-california.png "Form HBD-40 "Affidavit of Parent-Child Relationship" - California")
![Instructions for Form HBD-30 "Health Benefits Plan Enrollment for Retirees and Survivors" - California](https://data.templateroller.com/pdf_docs_html/1788/17882/1788224/health-benefits-plan-enrollment-retirees-and-survivors.png "Instructions for Form HBD-30 "Health Benefits Plan Enrollment for Retirees and Survivors" - California")
![Instructions for Form HBD-12 "Health Benefits Plan Enrollment for Active Employees" - California](https://data.templateroller.com/pdf_docs_html/1788/17882/1788225/health-benefits-plan-enrollment-active-employees.png "Instructions for Form HBD-12 "Health Benefits Plan Enrollment for Active Employees" - California")
![Form PERS-EAMD-139 "Notice of Exclusion From CalPERS Membership for Public Agency and Schools" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063480/form-pers-eamd-139-notice-of-exclusion-from-calpers-membership-for-public-agency-and-schools-california.png "Form PERS-EAMD-139 "Notice of Exclusion From CalPERS Membership for Public Agency and Schools" - California")
![Form PERS-BSD-194 "Report of Separation and Advance Payroll Information" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063487/form-pers-bsd-194-report-of-separation-and-advance-payroll-information-california.png "Form PERS-BSD-194 "Report of Separation and Advance Payroll Information" - California")
![Form PERS-MSD-371 "Request for Service Credit Cost Information - Leave of Absence" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063492/form-pers-msd-371-request-for-service-credit-cost-information-leave-of-absence-california.png "Form PERS-MSD-371 "Request for Service Credit Cost Information - Leave of Absence" - California")
![Form PERS-MSD-373 "Request for Service Credit Cost Information - Peace Corps, Americorps Vista, or Americorps Service Credit" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063491/form-pers-msd-373-request-for-service-credit-cost-information-peace-corps-americorps-vista-or-americorps-service-credit-california.png "Form PERS-MSD-373 "Request for Service Credit Cost Information - Peace Corps, Americorps Vista, or Americorps Service Credit" - California")
![Form PERS-MSD-370 "Request for Service Credit Cost Information - Service Prior to Membership" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063495/form-pers-msd-370-request-for-service-credit-cost-information-service-prior-to-membership-california.png "Form PERS-MSD-370 "Request for Service Credit Cost Information - Service Prior to Membership" - California")
![Form PERS-BSD-145 "Reinstatement From Service Retirement Application" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063486/form-pers-bsd-145-reinstatement-from-service-retirement-application-california.png "Form PERS-BSD-145 "Reinstatement From Service Retirement Application" - California")
![Form PERS-BSD-470 "Retirement Allowance Estimate Request" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063497/form-pers-bsd-470-retirement-allowance-estimate-request-california.png "Form PERS-BSD-470 "Retirement Allowance Estimate Request" - California")
![Form PERS-MSD-353 "Tier Conversion Cost Information Request" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063499/form-pers-msd-353-tier-conversion-cost-information-request-california.png "Form PERS-MSD-353 "Tier Conversion Cost Information Request" - California")
![Form PERS-MSD-369 "Request for Service Credit Cost Information - Military Service" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063490/form-pers-msd-369-request-for-service-credit-cost-information-military-service-california.png "Form PERS-MSD-369 "Request for Service Credit Cost Information - Military Service" - California")
![Form PERS-MSD-372 "Request for Service Credit Cost Information - Layoff, Prior Service, and Optional Member Service" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063496/form-pers-msd-372-request-for-service-credit-cost-information-layoff-prior-service-and-optional-member-service-california.png "Form PERS-MSD-372 "Request for Service Credit Cost Information - Layoff, Prior Service, and Optional Member Service" - California")
![Form PERS-MSD-374 "Request for Service Credit Cost Information - Base Realignment and Closure (Brac) Firefighter" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063489/form-pers-msd-374-request-for-service-credit-cost-information-base-realignment-and-closure-brac-firefighter-california.png "Form PERS-MSD-374 "Request for Service Credit Cost Information - Base Realignment and Closure (Brac) Firefighter" - California")
![Form PERS-OSS-138 "Special Power of Attorney" - California](https://data.templateroller.com/pdf_docs_html/2022/20229/2022985/form-pers-oss-138-special-power-of-attorney-california.png "Form PERS-OSS-138 "Special Power of Attorney" - California")
![Form PERS-EAMD-801 "Reciprocal Self-certification Form" - California](https://data.templateroller.com/pdf_docs_html/2009/20093/2009361/form-pers-eamd-801-reciprocal-self-certification-form-california.png "Form PERS-EAMD-801 "Reciprocal Self-certification Form" - California")
![Form HBD-85R "Cobra Election Form (Retirees)" - California](https://data.templateroller.com/pdf_docs_html/1788/17881/1788170/form-hbd-85r-cobra-election-form-retirees-california.png "Form HBD-85R "Cobra Election Form (Retirees)" - California")
![Form PERS-EAMD-139S "Notice of Exclusion From CalPERS Membership for State Agencies" - California](https://data.templateroller.com/pdf_docs_html/2063/20634/2063481/form-pers-eamd-139s-notice-of-exclusion-from-calpers-membership-for-state-agencies-california.png "Form PERS-EAMD-139S "Notice of Exclusion From CalPERS Membership for State Agencies" - California")
