Employee Forms and Applications

Employee Forms and Applications

Fillable PDFs can be saved to your desktop. However, applicants using Acrobat Reader, rather than Acrobat Standard or Pro, will only be able to print the information after it's filled out, not save. If using Standard or Pro, If using Standard or Pro, the filled out information can be saved. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version.

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.
Medical Only Employee Application
Employees should complete this form to enroll in a group medical plan. For employee enrollments
to a new or existing employer group.

Effective 1/1/2024
English (Fillable) 583 KB
Spanish (Fillable) 608 KB
Chinese (Fillable) 790 KB
Vietnamese (Fillable) 767 KB
Persian (Fillable) 781 KB

Effective 1/1/2023
English (Fillable) 904 KB
Spanish (Fillable) 1.5 MB
Chinese (Fillable) 1.8 MB
Vietnamese (Fillable) 1.6 MB
Persian (Fillable) 1.7 MB

Effective 1/1/2022
English (Fillable) 1.4 MB
Spanish (Fillable) 1.8 MB
Chinese (Fillable) 1.4 MB
Vietnamese (Fillable) 1.5 MB
Persian (Fillable) 1.4 MB

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 1/1/2024
English (Fillable) 452 KB
Spanish (Fillable) 460 KB
Chinese (Fillable) 613 KB
Vietnamese (Fillable) 541 KB
Persian (Fillable) 615 KB

Effective 1/1/2023
English (Fillable) 764 KB
Spanish (Fillable) 1.2 MB
Chinese (Fillable) 1.6 MB
Vietnamese (Fillable) 1.3 MB
Persian (Fillable) 1.4 MB

Effective 1/1/2022
English (Fillable) 1.2 MB
Spanish (Fillable) 1.2 MB
Chinese (Fillable) 1.5 MB
Vietnamese (Fillable) 1.3 MB
Persian (Fillable) 1.2 MB

Medical and Life 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.

Effective 1/1/2024
English (Fillable) 1 MB
Spanish (Fillable) 640 KB
Chinese (Fillable) 821 KB
Vietnamese (Fillable) 725 KB
Persian (Fillable) 806 KB

Effective 1/1/2023
English (Fillable) 938 KB
Spanish (Fillable) 1.5 MB
Chinese (Fillable) 1.9 MB
Vietnamese (Fillable) 1.6 MB
Persian (Fillable) 1.7 MB

Effective 1/1/2022​
English (Fillable) 1.4 MB
Spanish (Fillable) 1.4 MB
Chinese (Fillable) 1.8 MB
Vietnamese (Fillable) 1.5 MB
Persian (Fillable) 1.4 MB

 

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
Authorization for the Release of Health Information Download

 

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    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.