California Service Employees Health & Welfare Trust Fund (CalServ) fax number

Fax destination details

Department

Los Angeles Fringe Benefit Office (Membership Services)

Purpose

Enrollment processing and benefits inquiries; enrollment forms are submitted by mail or fax and processed by the Fund; COBRA and life/beneficiary forms may be requested or submitted as applicable.

Form

Enrollment Form — Enrollment Form

Address

828 W Washington Blvd, Los Angeles, CA 90015, United States

Voice phone

213-747-7551

Website

Visit organization website

Before you send

• Confirm that this exact department handles your document or request.
• Check the organization website or call its main line for the current fax number.
• Include a cover sheet and any case, member, claim, or form reference required.
• Keep the delivery confirmation with your submission records.

Instructions: Complete Sections I and II of the enrollment form, sign both signature lines; if enrolling a spouse attach a marriage certificate; if enrolling a child under 26 attach birth certificates; if enrolling a domestic partner include a Domestic Partner Application; if a dependent has no SSN, use the Safe Harbor form; submit by mail or in person or by fax, including name and SSN on each page to 213-747-2896.

Official form instructions are published as a downloadable file on the organization's website.