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December 27, 2016 | Print | Site Map | Help
 

Welcome

Pension Plan

 
Pension Application
  • Pension Application (File size - 156 K)
    Use this form to submit your application to the Plan Adminstrator

    This fill-in PDF form uses features best supported by Adobe Acrobat Reader. You may download Acrobat Reader for free from Adobe.
Death Benefit Application
  • There is no Death Benefit Application at this time.
Tax Forms
  • IRS Form W-4P (File size - 135 K)
    Withholding Certificate for Pension or Annuity Payments. Required to complete your election for federal tax withholding.
  • State of California Form DE 4P (File size - 414 K)
    Withholding Certificate for Pension or Annuity Payments. Required to complete your election for state tax withholding.
  • Tax Withholding Form (File size - 104 K)
    Use this form to designate Federal and State tax withholding
Other Forms
Annual Funding Notice
Notices of Endangered or Critical Status
Summary Annual Reports
  • There are no Summary Annual Reports at this time.

Contact Plan Administrator
regarding questions about your benefits

Telephone NumberPhone
(800) 782-0010

Contact FormEmail:
resilientinfo@hsba.com

Click for MapVisit Us
Health Services & Benefit Administrators, Inc. (HS&BA)
4160 Dublin Boulevard, Suite 400
Dublin, CA 94568-7756

Contact Website Technical Support
regarding questions related to the use of this web site.

Toll Free(866) 367-8265