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| Form | Download |
|---|---|
| Employee Application Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group. |
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| Medical only Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group. |
Effective 1/1/2023 Effective 1/1/2022 |
| Life Only Employee Application Employees should complete this form to enroll in a group term life policy. For employee enrollments to a new or existing employer group. |
Effective 1/1/2023 Effective 1/1/2022 |
| Medical and Life 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. |
Effective 1/1/2023 Effective 1/1/2022 |
| Form | Download |
|---|---|
| HIPPAA Release Form Authorization for the release of personal and health information. |
Download |
| Evidence of Insurability | Download |
| Refusal of Personal Coverage Form Employees should complete this form if they, their spouse/domestic partner of dependents are refusing their employer's medical or dental plan coverage. |
Download |
| Declaration of Disability of Over Age Dependent Children For enrolled dependent children who normally lose their eligibility because of age, but who are disabled by reason of a physically or mentally disabling injury. |
English Spanish |
| Subscriber Disability File for an extension of benefits. Administrators must also complete the Notice of Total and Permanent Disability Form. |
Download |
| Disability Addendum | Download |
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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.