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.
Online submissions are the only option for many submissions (see exceptions below):
EC+ supports the following member-level changes, with no need to submit a paper form:
EC+ does not support the following, and therefore the appropriate paper form will need to be submitted:
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
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. |
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Master Group Application As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes. |
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2021 Master Group Application New/renewing groups effective April 1, 2021 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2021 Master Group Application New/renewing groups effective January 1, 2021 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Master Group Application New/renewing groups effective October 1, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Master Group Application New/renewing groups effective July 1, 2020 through September 30, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Master Group Application New/renewing groups effective April 1, 2020 through June 30, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Master Group Application New/renewing groups effective January 1, 2020 through March 31, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2019 Master Group Application New/renewing groups effective October 1, 2019 through December 31, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2019 Master Group Application New/renewing groups effective July 1, 2019 through September 30, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2019 Master Group Application New/renewing groups effective April 1, 2019 through June 30, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2019 Master Group Application New/renewing groups effective January 1, 2019 through March 31, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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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) | ||
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) | ||
Small Group Owner Eligibility Statement Use this form for owners to attest for eligibility. |
Download (Fillable PDF) | ||
Group Information Update Form Use this form to update a Small Group's billing address or contact information. |
Download (Fillable PDF) | ||
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. |
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2021 Group Change Request New/renewing groups effective April 1, 2021 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2021 Group Change Request New/renewing groups effective January 1, 2021 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Group Change Request New/renewing groups effective October 1, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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Request for Contract Change Visit Online Renewals to submit changes, except for Specialty Benefits buy up for life insurance and coverage changes or plan additions for standalone Specialty Benefits (dental, vision, or life insurance only with no medical) coverage. |
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2020 Request for Contract Change New/renewing groups effective July 1, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Request for Contract Change New/renewing groups effective April 1, 2020 through June 30, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Request for Contract Change New/renewing groups effective January 1, 2020 through March 31, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2019 Request for Contract Change New/renewing groups effective October 1, 2019 through December 31, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2019 Request for Contract Change New/renewing groups effective July 1, 2019 through September 30, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2019 Request for Contract Change New/renewing groups effective April 1, 2019 through June 30, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2019 Request for Contract Change New/renewing groups effective January 1, 2019 through March 31, 2019 |
English (Fillable PDF) Spanish (Fillable PDF) |
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Multiple Subscriber Change Spreadsheet Submit subscriber-level enrollment changes. |
Download (Fillable PDF) | ||
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) | ||
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) POP allows premiums to be deducted on a pre-tax basis. Click download for informational flier and application. |
Download |
Forms |
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Enrollment Spreadsheet |
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Guide to Enrollment Spreadsheet | Download | ||
Enrollment Spreadsheet Flier | |||
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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2021 Employee Application New/renewing groups effective April 1, 2021 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2021 Employee Application New/renewing groups effective January 1, 2021 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Employee Application New/renewing groups effective October 1, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Employee Application New/renewing groups effective July 1, 2020 through September 30, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Employee Application New/renewing groups effective April 1, 2020 through June 30, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Employee Application New/renewing groups effective January 1, 2020 through March 31, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2019 Employee Application New/renewing groups effective October 1, 2019 through December 31, 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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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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2021 Subscriber Change Request New/renewing groups effective April 1, 2021 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2021 Subscriber Change Request New/renewing groups effective January 1, 2021 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Subscriber Change Request New/renewing groups effective October 1, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Subscriber Change Request New/renewing groups effective July 1, 2020 through September 30, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Subscriber Change Request New/renewing groups effective April 1, 2020 through June 30, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2020 Subscriber Change Request New/renewing groups effective January 1, 2020 through March 31, 2020 |
English (Fillable PDF) Spanish (Fillable PDF) |
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2019 Subscriber Change Request New/renewing groups effective October 1, 2019 through December 31, 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, 2019 |
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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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 Download (Fillable PDF) |
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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 checklist on whether your client qualifies for POP along with an application, download this informational brochure. |
Download | ||
CVS Mail Order Form | Download (Fillable PDF) |
Form |
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COBRA Continuation of Coverage Application |
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Continuation of Coverage Application (COBRA and Cal-COBRA) |
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Employer Notification of Qualifying Events under Cal-COBRA (ENF) |
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Employer Notification of Qualifying Events under Cal-COBRA |
Download |
Cal-COBRA Take-Over |
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Continuing Group Coverage after Federal COBRA Cal-COBRA Election |
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Cal-COBRA Election |
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Cal-COBRA Dental Election |
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Subscriber's Statement of Claim |
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Statement of Claim: Blue Shield Life |
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Authorization for Release of Personal and Health Information |
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Pharmacy Reimbursement |
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Blue Shield Global Core International Claim |
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Proof of Death Form: Group Life |
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Accelerated Death Benefit Claim Form: Group Life |
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Dismemberment Claim Form: Group Life |
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Dental Claim |
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Vision Claim |
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Waiver of Premium Claim Form: Group Life |
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Conversion to Individual Coverage: Group Life |
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Beneficiary Affidavit (life insurance groups of 10 or more) |
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Beneficiary Change Request Form |
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DOI |
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DMHC |
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Contact Us
Producer Services (800) 559-5905
Employer Services (800) 325-5166
Blue Shield of California
PO Box 272540
Chico, CA 95927-2540
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Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.