Forms and applications

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.