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. The SAG-AFTRA
Health Plan and the SAG-Producers Pension Plan share this information if you are a participant of both.
For more information about eligibility requirements, please visit www.sagaftraplans.org.
Please complete and sign below
Date of birth (MM/DD/YYYY):
/ /
Gender:
Male Female
Social Security number:
- -
Legal name (first, middle, last):
Professional name (first, middle, last):
Please indicate which name you prefer us to use when sending correspondence:
Legal Professional
Address 1:
Address 2:
City:
State:
Zip:
Country:
Mobile phone:
Alternate email:
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)
click to sign
signature
click to edit
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