Small Business Forms and applications
Small Businesses (1 to 100)
In our effort to provide easier access to the materials you need, we have consolidated all the Small Business forms and applications. We hope that this "one-stop-shop" page will be an easy reference point for all your forms/application needs and will aid your effort to continue providing excellent service to your Small Business clients.
Options for application submissions
Online submissions are the preferred option for many submissions (see exceptions below):
- For group renewal change submissions, please visit Online Renewals.
- When advised for Special Enrollment Periods.
The Employer Enrollment Tool supports Small Group quoting, new group enrollment, and group-level and member-level changes, with no need to submit a paper form.
The Employer Enrollment Tool does not support the following, and therefore the appropriate paper form will need to be submitted:
- Enrollment of subscribers without a Social Security Number
- Enrollment of court-ordered dependents as subscribers
- Cal-Cobra changes or management
- Reinstating an employer group
Email
Small.Group@blueshieldca.com
Our members' security is important to us. To assure the secure transmittal of this data, we recommend that you use a secure email system to transmit this required information.
Fax
(855) 808-8598
Attention: Small Group Installation and Billing
Mail
Blue Shield of California
Attn: Small Group Installation and Billing
P.O. Box 3008, Lodi, CA 95241-1912
Note: to download a form, go to "Print", select "Save as PDF," and click "Save"
Employer forms and applications (groups 1-100)
| Form | Download |
|---|---|
| Enrollment spreadsheet with master group application Use this form to submit both the Employee Enrollment Applications and Master Group Application in one integrated document. As a reminder, you must use the Enrollment Spreadsheet for your Employee Enrollment application if you submit the Master Group Application through this document. |
2022 - Q1 | Q2 | Q3 | Q4 |
| Master group application As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes. |
|
2024 Master group application |
English (Fillable PDF, 409 KB) Spanish (Fillable PDF, 366 KB) |
2024 Master group application |
English (Fillable PDF, 648KB) Spanish (Fillable PDF, 643KB) |
2023 Master group application |
English (Fillable PDF, 644KB) Spanish (Fillable PDF, 769KB) |
2023 Master group application |
English (Fillable PDF, 714KB) Spanish (Fillable PDF, 736KB) |
2022 Master group application |
English (Fillable PDF, 751KB) Spanish (Fillable PDF 677KB) |
2022 Master group application |
English (Fillable PDF, 1.3MB) Spanish (Fillable PDF 1.3MB) |
| Small group initial payment form Use this form as another option to submit your cases. Be sure to complete the form and include your client's signature and a voided check. |
Download (Fillable PDF, 73 KB) |
| Small group start-up/spin-off eligibility statement Use this form for start-up and spin-off groups to attest for eligibility. |
Download (Fillable PDF, 520 KB) |
| Small group owner eligibility statement Use this form for owners to attest for eligibility. |
Download (Fillable PDF, 492 KB) |
| Group change request This form replaces the “Request for Contract Change”, the “Group Information Update” and the “Group Name Change” forms for groups requesting changes effective October 1, 2020 and later. Use this form to change company information, contacts, group elections, or plans. |
|
2024 Group change request |
English (Fillable PDF, 440 KB) Spanish (Fillable PDF, 436 KB) |
2023 Group change request |
English (Fillable PDF, 664KB) Spanish (Fillable PDF, 657KB) |
2023 Group change request |
English (Fillable PDF, 724KB) Spanish (Fillable PDF, 635KB) |
2023 Group change request |
English (Fillable PDF, 672KB) Spanish (Fillable PDF, 714KB) |
2022 Group change request |
English (Fillable PDF, 742KB) Spanish (Fillable PDF, 721KB) |
2022 Group change request |
English (Fillable PDF, 1.17MB) Spanish (Fillable PDF, 2.1MB) |
| Multiple subscriber change spreadsheet Submit subscriber-level enrollment changes. |
Download (Fillable PDF, 83 KB) |
| Employee cancellation notification (formerly the employee change/cancellation transmittal) Use this form to terminate coverage for multiple employees. If applicable, use this form to provide notification of Cal-COBRA qualifying event due to termination, resignation, or reduction in employee hours. |
Download (Fillable PDF, 1.2 MB) |
| Small business cancellation form Use this form to cancel a group's coverage from Blue Shield for either Medical, Dental, Vision or Life |
Download (Fillable PDF, 635 KB) |
| CMS reporting form Submit this form to Blue Shield of California to ensure that you are reporting employees who may have Medicare as the Primary Payer. |
Download |
| Premium only plan (POP) HealthEquity POP allows premiums to be deducted on a pre-tax basis. Click download for informational flyer and application. |
Download |
| Small group broker of record change request | Download |
Employee forms and applications, including enrollment spreadsheet tool (groups 1-100)
| Form | Download |
|---|---|
| Enrollment spreadsheet |
2022 - Q1 | Q2 | Q3 | Q4 |
| Guide to enrollment spreadsheet | Download |
| Employee application Employees should complete this form to enroll in a group medical plan, group vision plan, or group term life policy. For employee enrollments to a new or existing employer group. As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes. |
|
2024 Employee application |
English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.2 MB) |
2024 Employee application |
English (Fillable PDF, 1.5MB) Spanish (Fillable PDF, 1.5MB) |
2023 Employee application |
English (Fillable PDF, 1.4MB) Spanish (Fillable PDF, 1.6MB) |
2023 Employee application |
English (Fillable PDF, 1.4MB) Spanish (Fillable PDF, 1.6MB) |
2022 Employee application |
English (Fillable PDF, 1.23MB) Spanish (Fillable PDF, 1.46MB) |
2022 Employee application |
English (Fillable PDF, 1.23MB) Spanish (Fillable PDF, 1.46MB) |
| Subscriber change request Employees can change personal information, change plans during open enrollment, enroll new dependents, or cancel dependents (please include the Refusal or Cancellation of Personal Coverage form). |
|
2024 Subscriber change request |
English (Fillable PDF, 1.1 MB) Spanish (Fillable PDF, 1.2 MB) |
2024 Subscriber change request |
English (Fillable PDF, 1.3MB) Spanish (Fillable PDF, 1.4MB) |
2023 Subscriber change request |
English (Fillable PDF, 1.3MB) Spanish (Fillable PDF, 1.4MB) |
2023 Subscriber change request |
English (Fillable PDF, 1.2MB) Spanish (Fillable PDF, 1.4MB) |
2022 Subscriber change request |
English (Fillable PDF, 1.2MB) Spanish (Fillable PDF, 1.15MB) |
2022 Subscriber change request |
English (Fillable PDF, 1.2MB) Spanish (Fillable PDF, 1.15MB) |
| Refusal of coverage Employees complete this form if they, their spouse/domestic partner, or other dependents refuse their employer’s medical or dental plan coverage |
|
Refusal of coverage form |
English (Fillable PDF, 556 KB) Spanish (Fillable PDF, 675 KB) |
| Continuity of care program brochure | English Spanish Chinese Vietnamese Hindi Korean |
| Request for continuity of care service for established members and new enrollees Members of HMO-only groups with qualifying conditions may be able to complete care with a non-network provider. |
English Spanish Chinese Vietnamese Hindi Korean |
| Authorization for the use or disclosure of health information | English Spanish Chinese Vietnamese Hindi Korean |
| Declaration of disability of over-age-dependent children For enrolled dependent children who normally lose their eligibility because of age but who have a physical or mental disabling injury. |
English Spanish |
| Waiver of premium claim form – life If a member becomes totally disabled, the life premium may be waived. |
Download |
| Premium only plan (POP) HealthEquity's POP lets employers cut payroll taxes without cutting payroll. If an employer requires employees to contribute to the cost of their insurance, a Section 125 POP allows them to do so with pre-tax dollars. |
Download |
| CVS mail order form | Download |
COBRA and CAL-COBRA
| Form | Download |
|---|---|
| Continuation of Coverage Application (COBRA and Cal-COBRA) For existing groups requesting effective dates of October 1, 2020, and later, this form replaces the "COBRA Continuation of Coverage Application”, the “Cal-COBRA Election”, the "Cal-COBRA Dental Election", and the “Continuing Group Coverage After Federal COBRA” forms. Use this form to apply for a continuation of coverage (federal COBRA or Cal-COBRA). |
Download (Fillable PDF) |
| Employer Notification of Qualifying Events under Cal-COBRA This form replaces the “Employer Notification of Qualifying Events under Cal-COBRA (ENF)” form for groups requesting changes effective October 1, 2020, and later. Complete this form each time a covered employee has a qualifying event that causes them to be eligible for continuation coverage under the California Continuation Benefits Replacement Act (Cal-COBRA). |
Download (Fillable PDF) |
| Cal-COBRA Take-Over New groups should use this form when changing carriers to Blue Shield for Cal-COBRA members covered under a previous carrier. Employers are responsible for notifying their Cal-COBRA members of the transition to a new carrier and Cal-COBRA members are required to fill out the form and submit it to the Cal-COBRA team within 30 days of transition. |
Download (Fillable PDF) |
Cal-COBRA Election form This form is for members to enroll in Cal-COBRA is they have exhausted their Federal Cal-COBRA coverage, are not eligible for Federal Cal-COBRA coverage due to their employer's type of coverage, or are moving from another carrier's Cal-COBRA policy to a Cal-COBRA policy under Blue Shield. |
Download (Fillable PDF) |
Claims
| Form | Download |
|---|---|
| Subscriber's Statement of Claim | Download |
| American Specialty Health (ASH) – Subscriber Claim form | Download |
| Out of State Claim form (Travel Reimbursement) | Download |
| Out of State Claim form | Download |
| Authorization for Release of Personal and Health Information | Download |
| Prescription Drug Reimbursement form | English Spanish |
| Blue Shield Global Core International Claim | |
| Proof of Death Form: Group Life | Download |
| Accelerated Death Benefit Claim Form: Group Life | Download |
| Dismemberment Claim form: Group Life | |
| Dental Claim | Download |
| Vision Claim | Download |
| Waiver of Premium Claim form: Group Life If a member becomes totally disabled, the life premium may be waived. |
Download |
| Beneficiary Affidavit & Assignment form | Download |
| Beneficiary Change Request | English Spanish |
Specialty benefits
*Translations temporarily unavailable.
**Underwritten by Blue Shield of California Life & Health Insurance Company.
