Forms and Applications Small Businesses (1 to 100)
Broker Resources
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In our effort to provide easier access to 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.
- Employer forms and applications
- Employee forms and applications
- Specialty benefits
- Claim forms
- COBRA/Cal-COBRA
Fillable PDFs
Your groups can easily enter information directly to the PDF. Once a fillable PDF is saved to the desktop, you cannot go back and make changes.
Options for application submissions
Reminder: We no longer accept paper for many submissions.
Online: the only option for many submissions (see exceptions below)
- For member maintenance submission, please visit Employer Connection Plus
- For group change submissions, please visit Online Renewals
Exceptions for using our online system. Please use the applicable forms via fax or email for the following:
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Life Insurance buy up for groups with 10 or more enrolled employees
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Life Insurance plan changes for groups currently composite rated
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COBRA and Cal-COBRA changes or additions (group and member level)
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Add a second waiting period based on employee class
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Changing domestic partner coverage (narrow/broad)
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Employer contribution changes
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Adding or removing part-time employee coverage
Email
Small.Group@blueshieldca.com
Our members' security is important to us. To assure the secured 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
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Forms |
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Enrollment Spreadsheet |
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| Guide to Enrollment Spreadsheet | Download | ||
| Enrollment Spreadsheet Flier | 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. |
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| 2019 Employee Application New/renewing groups effective October 1, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2019 Employee Application New/renewing groups effective July 1, 2019 through September 30, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2019 Employee Application New/renewing groups effective April 1, 2019 through June 30, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2019 Employee Application New/renewing groups effective January 1, 2019 through March 31, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2018 Employee Application New/renewing groups effective October 1, 2018 through December 31, 2018 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2018 Employee Application New/renewing groups effective July 1, 2018 through September 30, 2018 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2018 Employee Application New/renewing groups effective April 1, 2018 through June 30, 2018 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2018 Employee Application New/renewing groups effective January 1, 2018 through March 31, 2018 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| Subscriber Change Request Employees can change personal information, change plans during open enrollment, enroll new dependents, or cancel dependents (include Refusal or Cancellation of Personal Coverage form). |
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| 2019 Subscriber Change Request New/renewing groups effective October 1, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2019 Subscriber Change Request New/renewing groups effective July 1, 2019 through September 30, 2018 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2019 Subscriber Change Request New/renewing groups effective April 1, 2019 through June 30, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2019 Subscriber Change Request New/renewing groups effective January 1, 2019 through March 31, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2018 Subscriber Change Request New/renewing groups effective October 1, 2018 through December 31, 2018 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2018 Subscriber Change Request New/renewing groups effective July 1, 2018 through September 30, 2018 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2018 Subscriber Change Request New/renewing groups effective April 1, 2018 through June 30, 2018 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 2018 Subscriber Change Request New/renewing groups effective January 1, 2018 through March 31, 2018 |
English (Fillable PDF) Spanish (Fillable PDF) |
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| 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. |
Download (Fillable PDF) | ||
| Continuity of Care program brochure | English Spanish Chinese Vietnamese Hindi Korean |
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| 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 |
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| Authorization for the use or disclosure of health information | English Spanish Chinese Vietnamese Hindi Korean |
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| Continuity of care notice for new HMO enrollees Important notice for new HMO enrollees. |
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| 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. |
Download | ||
| Waiver of Premium Claim Form – Life If a member becomes totally disabled, the life premium may be waived. |
Download | ||
| Premium Only Plan (POP) The premium only plan lets employers cut payroll taxes without cutting payroll. If an employer requires employees to contribute to the cost of their insurance, a Section 125 Premium Only Plan (POP) allows them to do so with pre-tax dollars. For a check list on whether your client qualifies for POP along with an application, download this informational brochure. |
Download | ||
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| Form | Download | |
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| COBRA Employee Application | Download* | |
| Employer Notification of Qualifying Events under Cal-COBRA (ENF) Complete this form when covered employees have an event that qualifies them for coverage under the California Continuation Benefits Replacement Act (Cal-COBRA, California Senate Bill 719) |
Download | |
| 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 fill out the form and submit to the Cal-COBRA team within 30 days of transition. |
Download | |
| Continuing Group Coverage after Federal COBRA Cal-COBRA Election After exhausting 18 months of Federal COBRA benefits, a beneficiary may be eligible to an 18-month extension through Cal-COBRA. Beneficiary must contact Cal-COBRA (800) 228-9476 to request the extension and ensure they meet the requirements. If approved, the beneficiary will submit this form to formally accept the extension. |
Download | |
| Cal-COBRA Election Once the employer submits the ENF, an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without employer first submitting the ENF. |
Download | |
| Cal-COBRA Dental Election For dental only groups: Once the employer submits the ENF, an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without employer first submitting the ENF. |
Download |
