PORAC RMT Participant Data Form

Administered by Benefit Programs Administration
1200 Wilshire Blvd, 5th Floor • Los Angeles, CA 90017
Telephone: (877) 808-5994 • Fax (562) 463-5894
Email: PORACRMT@bpabenefits.com
Participant Data Form
EMPLOYER INFORMATION
Employer Name*
New HireSeparation/ RetirementSeparation Gross MisconductAddress ChangeDependent ChangeName ChangeMarital Status Change
ActiveRetiredTerminated
MEMBER INFORMATION
Member Name*

First NameMiddle InitialLast Name
Social Security Number (SSN)*
MaleFemale
Date of Birth (MM/DD/YYYY)*

MonthDayYear
Date of Hire (MM/DD/YYYY)*

MonthDayYear
SingleMarriedDivorcedWidowedRemarried
Date of Marriage / Divorce (MM/DD/YYYY)

MonthDayYear
Member Mailing Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member Phone*
Format: (000) 000-0000.
Member Email*
example@example.com
DEPENDENT INFORMATION
Dependent Full Name
Date of Birth

MonthDayYear
Date
Relation to Employee
MaleFemale
Social Security Number (SSN)
Dependent Full Name
Date of Birth

MonthDayYear
Date
Relation to Employee
MaleFemale
Social Security Number (SSN)
Dependent Full Name
Date of Birth

MonthDayYear
Date
Relation to Employee
MaleFemale
Social Security Number (SSN)
Dependent Full Name
Date of Birth

MonthDayYear
Date
Relation to Employee
MaleFemale
Social Security Number (SSN)
Dependent Full Name
Date of Birth

MonthDayYear
Date
Relation to Employee
MaleFemale
Social Security Number (SSN)
Dependent Full Name
Date of Birth

MonthDayYear
Date
Relation to Employee
MaleFemale
Social Security Number (SSN)
AUTHORIZATION
Member / Employer Signature*
Date

MonthDayYear
Date
Should be Empty:

Participant Data Form

EMPLOYER INFORMATION

MEMBER INFORMATION

DEPENDENT INFORMATION

AUTHORIZATION