Fillable Participant Information Form Please update us every time (SAG-AFTRA Plans)

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Participant Information Form Please update us every time (SAG-AFTRA Plans)

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SAG-AFTRA HEALTH PLAN
SAG-PRODUCERS PENSION PLAN
3601 W. Olive Ave., Burbank, CA 91505 • Mailing Address: P.O. Box 7830, Burbank, CA 91510-7830
P (800) 777-4013 • F (818) 953-9880 • www.sagaftraplans.org
Participant Information Form
Please update us every time you change your address, phone number and/or email. This information is shared
between the SAG-AFTRA Health Plan and the SAG-Producers Pension Plan if you are a participant of both Plans.
For more information about eligibility requirements with these Plans, please visit www.sagaftraplans.org.
Please tell us about you
Legal name* (first, middle, last):
Date of birth (MM/DD/YYYY):
/ /
Gender:
☐Male ☐Female
Social Security number:
- -
Address 1:
Address 2:
City:
State:
Zip:
Country:
Alternate email:
Mobile phone:
This is a confidential legal document and must be signed by the participant before it can be accepted as a
valid record. If the participant is a minor, the parent or legal guardian must sign this document.
Signature Date
Relation to participant (if participant is a minor)
*We require your full legal name to administer your benefits.
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Participant Information Form Please update us every time (SAG-AFTRA Plans)

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Completed 20 January 2021

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