Active Health & Welfare – Plan Documents & Forms
Fillable PDF Forms
Some PDF forms on this site are fillable online. You can type information directly onto the PDF.
By default, Firefox does not currently support forms in fillable format. To use this feature, view the site in Chrome or Microsoft Edge.
Plan Documents & Amendments
Enrollment
Plan A Enrollment Guide
Plan A New Member Enrollment Form
Plan A Enrollment Change Form
Plan B Enrollment Guide
Plan B New Member Enrollment Form
Plan B Enrollment Change Form
Plan C Enrollment Guide
Plan C New Member Enrollment Form
Plan C Enrollment Change Form
Plan K20 Enrollment Guide
Plan K500 Enrollment Guide
Plan K1000 Enrollment Guide
Plan K New Member Enrollment Form
Plan K Enrollment Change Form
Summary of Benefits & Coverage
Active HW – Plan A
Plan A-Anthem SBC
Plan A-Kaiser SBC
Active HW – Plan B
Plan B-Anthem SBC
Plan B-Kaiser SBC
Active HW – Plan C
Plan C-Anthem SBC
Plan C-Kaiser SBC