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Forms and applications | Summary of Benefits (SOB) | Evidence of Coverage (EOC) l Small Business Home

Documents Library

Find useful documents from across the small business Broker Connection pages organized from A to Z.

2020 Employee Application - January 1, 2020 - March 31, 2020 English | Spanish
2020 Master Group Agreement - January 1, 2020 - March 31, 2020 English | Spanish
2020 Request for Contract Change - January 1, 2020 - March 31, 2020 English | Spanish
2020 Subscriber Change Request - January 1, 2020 - March 31, 2020 English | Spanish
2020 Enrollment spreadsheet with MGA - Jan. 1, 2020
2019 Employee Application - October 1, 2019 - December 31, 2019 English | Spanish
2019 Master Group Agreement - October 1, 2019 - December 31, 2019 English | Spanish
2019 Request for Contract Change - October 1, 2019 - December 31, 2019 English | Spanish
2019 Subscriber Change Request - October 1, 2019 - September 31, 2019 English | Spanish
2019 Enrollment Spreadsheet with MGA - October 1, 2019 - December 31, 2019
2019 Employee Application - July 1, 2019 - September 30, 2019 English | Spanish
2019 Master Group Agreement - July 1, 2019 - September 30, 2019 English | Spanish
2019 Request for Contract Change - July 1, 2019 - September 30, 2019 English | Spanish
2019 Subscriber Change Request - July 1, 2019 - September 30, 2019 English | Spanish
2019 Enrollment Spreadsheet with MGA - July 1, 2019 - September 30, 2019
2019 Employee Application - April 1, 2019 - June 30, 2019  English | Spanish
2019 Master Group Agreement - April 1, 2019 - June 30, 2019 English | Spanish
2019 Request Contract Change - April 1, 2019 - June 30, 2019 English | Spanish
2019 Subscriber Change Request - April 1, 2019 - June 30, 2019 English | Spanish
2019 Employee Application - January 1, 2019 - March 31, 2019 English | Spanish
2019 Master Group Agreement - January 1, 2019 - March 31, 2019 English | Spanish
2019 Request Contract Change - January 1, 2019 - March 31, 2019 English |Spanish
2019 Subscriber Change Request - January 1, 2019 - March 31, 2019 English | Spanish
2020 Plan Cheat Sheet
2020 Plans at a Glance
2020 Small Business Administrator's Guide
2020 Underwriting Guidelines
2019 Network Guide
2019 Plan Cheat Sheet
2019 Plans at a Glance
2019 Small Business Administrator's Guide
2019 Underwriting Guidelines
Accelerated Death Benefit Claim
Access to Care | Spanish
Additional Contact Designation: Notice of Lapse or Term of Policy for Non-Payment
Authorization to Disclose Health Information
Beneficiary Affidavit
Beneficiary Change Request
Eligibility/Participation Attestation
Standard Drug Formulary
BlueCard Flier
BlueCard Worldwide International Claim
Book of Business Transfer Request
Broker Direct Deposit Authorization Form
Broker Open Enrollment Presentation
Bundled Savings
Cal-COBRA Dental Election
Cal-COBRA Election
Cal-COBRA Continuation of Coverage
Cal-COBRA Notice of Qualifying Event 
Caries Risk Management Assessment
Changes To for HMO Mirror
Changes To for HMO Off-Exchange
Changes To for PPO Mirror
Changes To for PPO Off-Exchange
Changes To for PPO Savings Off-Exchange
Changes To Medical Plan Names
CMS Reporting
COBRA Employee Application
Continuing Group Coverage after Federal COBRA Cal-COBRA Election
Conversion to Individual Coverage of Group Life
CVS Caremark RX Mail Order
Declaration of Disability of Over Age Dependent Children
Dental Brochure for Brokers - Q1 2020
Dental Brochure for Brokers - Q4 2019
Dental Claim
Dental Implant Benefit FAQ | Spanish
Dental Network Map
Dental Nomination Form
Dental Plan Competitive Highlights
Dental Smile Rollover Rewards
Direct Elite Rewards
Dismemberment Claim
Employee Change/ Cancellation Transmittal
Employer Notification of Qualifying Event under Cal-COBRA
EPIC Hearing Aid
Express Enrollment
Find A Doctor
Group Information Update
Guide to Manage Dental Plan Online
Heal
Introducing Tandem PPO
Life Insurance Brochure for Brokers - Q1 2020
Life Insurance Brochure for Brokers - Q1 2019
Mail Service Prescriptions | Spanish
Managing your Vision Plan Online
Medical Incentive Bonus Program
Member Guide to Orthodontic Coverage | Spanish
Member ID Protection | Spanish
Notice Informing Individual about Nondiscrimination and Accessibility Requirements
Notification of CMS Reporting Requirements
NurseHelp 24/7 | Spanish
Owner Eligibility Attestation
Online and Mobile Tools | Spanish
Pediatric Dental and Vision Coverage
Pharmacy Reimbursement
Premium Only Plan (POP)
Print or Order ID Card | Spanish
Preventive Health Guidelines | Spanish
Privacy Policy | Spanish
Proof of Death
Quick Match Program 
Recertification Guidelines
Refusal of Coverage
Relaxed Participation
Request for COC Notice - HMO Enrollees
Request for COC Service - Members or New Enrollees
Sales Guide - Q1 2020
Sales Guide - Q4 2019
Sales Guide - Q3 2019
Sales Guide - Q2 2019
Small Business Tiered Pharmacy Network CA Level A Pharmacy Directory
Small Group Initial Payment Form
Shield Concierge
Small Business Online Roadshow Presentation | Recording | Questions Answered
Small Group Producer of Record Change Request
Sole Proprietor, Partner of Corporate Office Statement
Specialty Drug List for Standard Drug Formulary
Specialty Broker Bonus
Specialty Quick Facts
Start-up / Spin-off Eligibility Attestation
Subscriber Statement of Claim
Subscriber Statement of Claim - Life
Summary of Benefit FAQ
Teladoc 2019
Teladoc 2020 | Spanish
Tiered Pharmacy Network 
Tivity Health Fitness Your Way | Spanish
Trio Flier
Trio Qualification Tool
Total Health and Wellness | Spanish
Vaccine List
Vision Brochure - Q1 2020
Vision Brochure - Q1 2019
Vision Claim
Vision Network at a Glance
Vision Plan Info Card for CA Members | Spanish
Vision Plan Info Card for Out-Of-State Members
Waiver of Premium Claim
Wellness Discounts
Wellvolution
What's New - Q4 2019
What's New - Q3 2019
What's New - Q2 2019
What's New - Q1 2019
Why Blue Shield | Spanish
Why Blue Shield Small Business
Women's Preventive Health

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