Forms and applications

Small Businesses (1 to 100)

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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.

Options for application submissions

Online submissions are the only option for many submissions (see exceptions below):

For member maintenance submission, please visit Employer Connection Plus (EC+).
For group renewal change submissions, please visit Online Renewals.
When advised for Special Enrollment Periods.

EC+ supports the following member-level changes, with no need to submit a paper form:

Add a second waiting period based on employee class.
Adding or removing part-time employee coverage.
COBRA changes or additions (member-level).

EC+ does not support the following, and therefore the appropriate paper form will need to be submitted:

Life Insurance buy up for groups with 10 or more enrolled employees.
Life Insurance plan changes for groups currently composite rated.
Employer contribution changes.
Cal-COBRA changes or additions (group and member level).

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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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.		2021 - Q1 2020 - Q4 2020 - Q3 2020 - Q2 2020 - Q1
Master Group Application As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes.
	2021 Master Group Application New/renewing groups effective April 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2021 Master Group Application New/renewing groups effective January 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Master Group Application New/renewing groups effective October 1, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Master Group Application New/renewing groups effective July 1, 2020 through September 30, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Master Group Application New/renewing groups effective April 1, 2020 through June 30, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Master Group Application New/renewing groups effective January 1, 2020 through March 31, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Master Group Application New/renewing groups effective October 1, 2019 through December 31, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Master Group Application New/renewing groups effective July 1, 2019 through September 30, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Master Group Application New/renewing groups effective April 1, 2019 through June 30, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Master Group Application New/renewing groups effective January 1, 2019 through March 31, 2019	English (Fillable PDF) Spanish (Fillable PDF)
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.
	2021 Group Change Request New/renewing groups effective April 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2021 Group Change Request New/renewing groups effective January 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Group Change Request New/renewing groups effective October 1, 2020	English (Fillable PDF) Spanish (Fillable PDF)
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.
	2020 Request for Contract Change New/renewing groups effective July 1, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Request for Contract Change New/renewing groups effective April 1, 2020 through June 30, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Request for Contract Change New/renewing groups effective January 1, 2020 through March 31, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Request for Contract Change New/renewing groups effective October 1, 2019 through December 31, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Request for Contract Change New/renewing groups effective July 1, 2019 through September 30, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Request for Contract Change New/renewing groups effective April 1, 2019 through June 30, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Request for Contract Change New/renewing groups effective January 1, 2019 through March 31, 2019	English (Fillable PDF) Spanish (Fillable PDF)
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

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Forms
Enrollment Spreadsheet		2021 - Q1 2020 - Q4 2020 - Q3 2020 - Q2 2020 - Q1
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.
	2021 Employee Application New/renewing groups effective April 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2021 Employee Application New/renewing groups effective January 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Employee Application New/renewing groups effective October 1, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Employee Application New/renewing groups effective July 1, 2020 through September 30, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Employee Application New/renewing groups effective April 1, 2020 through June 30, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Employee Application New/renewing groups effective January 1, 2020 through March 31, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Employee Application New/renewing groups effective October 1, 2019 through December 31, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Employee Application New/renewing groups effective July 1, 2019 through September 30, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Employee Application New/renewing groups effective April 1, 2019 through June 30, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Employee Application New/renewing groups effective January 1, 2019 through March 31, 2019	English (Fillable PDF) Spanish (Fillable PDF)
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).
	2021 Subscriber Change Request New/renewing groups effective April 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2021 Subscriber Change Request New/renewing groups effective January 1, 2021	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Subscriber Change Request New/renewing groups effective October 1, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Subscriber Change Request New/renewing groups effective July 1, 2020 through September 30, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Subscriber Change Request New/renewing groups effective April 1, 2020 through June 30, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2020 Subscriber Change Request New/renewing groups effective January 1, 2020 through March 31, 2020	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Subscriber Change Request New/renewing groups effective October 1, 2019 through December 31, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Subscriber Change Request New/renewing groups effective July 1, 2019 through September 30, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Subscriber Change Request New/renewing groups effective April 1, 2019 through June 30, 2019	English (Fillable PDF) Spanish (Fillable PDF)
	2019 Subscriber Change Request New/renewing groups effective January 1, 2019 through March 31, 2019	English (Fillable PDF) Spanish (Fillable PDF)
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
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
Continuity of care notice for new HMO enrollees Important notice for new HMO enrollees.		Download
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)
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)

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Form	Download
COBRA Continuation of Coverage Application For groups requesting effective dates prior to October 1, 2020. Use this form to apply for COBRA continuation of coverage.	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”, 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 (ENF) For effective dates prior to October 1, 2020. 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
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 to the Cal-COBRA team within 30 days of transition.	Download
Continuing Group Coverage after Federal COBRA Cal-COBRA Election For groups requesting effective dates prior to October 1, 2020. After exhausting 18 months of Federal COBRA benefits, a beneficiary may be eligible for an 18-month extension through Cal-COBRA. The 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 the employer first submitting the ENF.	Download
Cal-COBRA Dental Election For groups requesting effective dates prior to October 1, 2020. 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 the employer first submitting the ENF.	Download

Form
DOI	English \| Spanish
DMHC	English \| Spanish \| Chinese \| Hindi \| Vietnamese \| Korean

Form		Download
Subscriber's Statement of Claim		Download
Statement of Claim: Blue Shield Life		Download
Authorization for Release of Personal and Health Information		Download
Pharmacy Reimbursement		Download
Blue Shield Global Core International Claim		Download
Proof of Death Form: Group Life		Download
Accelerated Death Benefit Claim Form: Group Life		Download
Dismemberment Claim Form: Group Life		Download
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

Form		Download
Conversion to Individual Coverage: Group Life		Download
Beneficiary Affidavit (life insurance groups of 10 or more)		Download
Beneficiary Change Request Form		Download