Declaration of Health Coverage (HBD-12A)

As part of any health plan enrollment or change, you are required to complete/submit a CalPERS Declaration of Health Coverage (HBD12-A)

Applicant Instructions

1. After launching the CalPERS Declaration of Health Coverage (HBD-12A), a DocuSign PowerForm will prompt you for your name and email.
2. Complete all required fields
3. The following information is needed to complete the CalPERS Declaration of Health Coverage (HBD-12A)
   • Employee Information: Name and social security number