|Standalone Specialty Benefits Employer Application
Dental, Vision & Life Insurance
|Conversion to Individual Coverage: Group Life||Download|
|Beneficiary Affidavit & Assignment Form||Download|
|Beneficiary Change Request||Download|
|Waiver of Premium Claim Form: Group Life
If a member becomes totally disabled, the life premium may be waived
Producer Services (800) 559-5905
Employer Services (800) 325-5166
Blue Shield of California
PO Box 272540
Chico, CA 95927-2540
© California Physicians’ Service DBA Blue Shield of California 1999-2022. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association.
Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.