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):
Social Security number:
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.
Relation to participant (if participant is a minor)
*We require your full legal name to administer your benefits.