NEW: Complete & Print Forms - You can complete most of the forms listed below right on your computer before you print. Simply click on the form and type in the appropriate information. Then print the completed form, sign and mail it to the Plan Office. Forms with this feature are indicated below with the "COMPLETE & PRINT " notation.

• Student Certification Form - COMPLETE & PRINT Dependent children are covered on the Health Plan through age 22 if full-time students. This form (and a new Performer Information Form, if dependent did not appear on the last PIF you submitted) should be completed and mailed to the Burbank Plan Office, Attention: PED.
• Privacy Notice - The privacy of your personal health information has always been of paramount importance to the Plan. Recent federal regulations require that the Plan provide all participants with a written notice of its privacy practices. This notice can be viewed here.
• Performer Information Form - COMPLETE & PRINT The "Performer Information Form" (formerly the Master Data Card) is the primary source for enrollment information for each participant. It also includes your designation of beneficiary. Please refer to the instructions on the second page when completing this card.
• Change of Address Card - COMPLETE & PRINT The change of address card may be downloaded, printed, completed, signed, and faxed or mailed to the plan office.
• Annual Summary of Earnings - This is a record of all session and residual earnings reported on your behalf to the Pension and Health Plans during the calendar year. It also reflects your total Pension Credits and accrued benefits under the Pension Plan.
• Authorization For Release of Health Information - This form is used when a participant wishes to authorize that their health information be disclosed to a particular person or organization. If you wish to designate someone to handle a health claim appeal on your behalf, please use the Authorized Representative Designation form.
• Authorized Representative Designation - This form is used when a participant wishes to designate someone, including a provider, to handle a health claim appeal on their behalf. If you wish to authorize that your health information be disclosed to someone for purposes other than a health claim appeal, please use the Authorization For Release of Health Information form.
• Notice of Creditable Coverage - This Notice contains important information about the prescription drug coverage with the SAG-Producers Health Plan and the Medicare Prescription Drug Plan (PDP) coverage.

• Domestic Partner Enrollment Kit Cover Letter - This letter gives you a clear introduction to each component of the domestic partnership enrollment kit.
• Domestic Partner Enrollment Q & A - This gives you the answers to many questions you may have regarding the program.
• California AB25 Information Sheet - Important Tax Information - California Law Assembly Bill 25 was passed to give same-sex couples the right to register their committed relationship with the State of California. This document is for California participants, and explains the tax consequences and Plan procedures which are affected.
• Affidavit of Domestic Partnership - COMPLETE & PRINT This affidavit is where you assert that the relationship of mutual financial support between you and your domestic partner is equivalent to that of marriage. You must submit the notarized original to the Plan office.
• Affidavit of Dependency for Domestic Partnership - COMPLETE & PRINT This is required by the the IRS and must also be notarized.
• Statement of Domestic Partnership Disenrollment - COMPLETE & PRINT This statement must be filed with the Plan Office within 10 days if your domestic partnership ends.
• Domestic Partner Enrollment Worksheet - This is your checklist of all the neccesary enrollment materials. Use it to make sure your enrollment is complete so you can avoid delays.
• Performer Information Form - COMPLETE & PRINT The "Performer Information Form" is the primary source for enrollment information for each participant. It also includes your designation of beneficiary. Please refer to the instructions on the second page when completing this card.