Employer 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
Master Group Application Note: Microsoft Edge is not recommended for viewing or downloading these forms.	Effective 1/1/2024 English (Fillable) 1.4 MB Spanish (Fillable) 1.3 MB Chinese (Fillable) 2.4 MB Vietnamese (Fillable) 2.1 MB Persian (Fillable) 2.3 MB Effective 1/1/2023 English (Fillable) 1.3 MB Spanish (Fillable) 697 KB Chinese (Fillable) 863 KB Vietnamese (Fillable) 815 KB Persian (Fillable) 815 KB Effective 1/1/2022 English (Fillable) 1.8 MB Spanish (Fillable) 1.5 MB Chinese (Fillable) 2.2 MB Vietnamese (Fillable) 1.8 MB Persian (Fillable) 1.6 MB
Welcome letter and checklist Use this customizable employer welcome letter and checklist to help simplify the enrollment process.	Download (Fillable)
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).	Effective 1/1/2024 English (Fillable) 1.1 MB Spanish (Fillable) 1.2 MB Chinese (Fillable) 1.4 MB Vietnamese (Fillable) 1.3 MB Persian (Fillable) 1.4 MB Effective 1/1/2023 English (Fillable) 545 KB Spanish (Fillable) 551 KB Chinese (Fillable) 733 KB Vietnamese (Fillable) 561 KB Persian (Fillable) 691 KB Effective 1/1/2022 English (Fillable) 948 KB Spanish (Fillable) 972 KB Chinese (Fillable) 691 KB Vietnamese (Fillable) 1 MB Persian (Fillable) 957 KB
Employee Change/Cancellation Transmittal Submit a monthly summary of employee cancellations and/or changes.	Download
Employer Questionnaire	Download (Fillable)