Forms and applications

Small Businesses (1 to 100)

Broker Resources

In our effort to provide easier access to the materials you need, we have consolidated all the Small Business forms and applications. We hope that this "one-stop-shop" page will be an easy reference point for all your forms/application needs and will aid your effort to continue providing excellent service to your Small Business clients.

Options for application submissions

Online submissions are the only option for many submissions (see exceptions below):

For group renewal change submissions, please visit Online Renewals.
When advised for Special Enrollment Periods.

EC+ supports the following member-level changes, with no need to submit a paper form:

Add a second waiting period based on employee class.
Adding or removing part-time employee coverage.
COBRA changes or additions (member-level).

EC+ does not support the following, and therefore the appropriate paper form will need to be submitted:

Life Insurance buy up for groups with 10 or more enrolled employees.
Life Insurance plan changes for groups currently composite rated.
Employer contribution changes.
Cal-COBRA changes or additions (group and member level).

Email
Small.Group@blueshieldca.com
Our members' security is important to us. To assure the secure transmittal of this data, we recommend that you use a secure email system to transmit this required information.

Fax
(855) 808-8598
Attention: Small Group Installation and Billing

Mail
Blue Shield of California
Attn: Small Group Installation and Billing
P.O. Box 3008, Lodi, CA 95241-1912

Note: to download a form, go to "Print", select "Save as PDF," and click "Save".

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Form		Download
Enrollment Spreadsheet with Master Group Application Use this form to submit both the Employee Enrollment Applications and Master Group Application in one integrated document. As a reminder, you must use the Enrollment Spreadsheet for your Employee Enrollment application if you submit the Master Group Application through this document.		2023 - Q1 \| Q3 2022 - Q1 \| Q2 \| Q3 \| Q4
Master Group Application As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes.
	2023 Master Group Application New/renewing groups effective July 1, 2023	English (Fillable PDF, 644 KB) Spanish (Fillable PDF, 769 KB)
	2023 Master Group Application New/renewing groups effective January 1, 2023	English (Fillable PDF, 714 KB) Spanish (Fillable PDF, 736 KB)
	2022 Master Group Application New/renewing groups effective October 1, 2022	English (Fillable PDF, 751 KB) Spanish (Fillable PDF 677 KB)
	2022 Master Group Application New/renewing groups effective January 1, 2022	English (Fillable PDF, 1.3 MB) Spanish (Fillable PDF 1.3 MB)
	2021 Master Group Application New/renewing groups effective October 1, 2021	English (Fillable PDF 1.7 MB) Spanish (Fillable PDF 1.6 MB)
	2021 Master Group Application New/renewing groups effective July 1, 2021	English (Fillable PDF 1.9 MB) Spanish (Fillable PDF 2.4 MB)
Small Group Initial Payment Form Use this form as another option to submit your cases. Be sure to complete the form and include your client's signature and a voided check.		Download (Fillable PDF)
Small Group Start-up/Spin-Off Eligibility Statement Use this form for start-up and spin-off groups to attest for eligibility.		Download (Fillable PDF)
Small Group Owner Eligibility Statement Use this form for owners to attest for eligibility.		Download (Fillable PDF)
Group Change Request This form replaces the “Request for Contract Change”, the “Group Information Update” and the “Group Name Change” forms for groups requesting changes effective October 1, 2020 and later. Use this form to change company information, contacts, group elections, or plans.
	2023 Group Change Request New/renewing groups effective July 1, 2023	English (Fillable PDF, 724 KB) Spanish (Fillable PDF, 635 KB)
	2023 Group Change Request New/renewing groups effective January 1, 2023	English (Fillable PDF, 672 KB) Spanish (Fillable PDF, 714 KB)
	2022 Group Change Request New/renewing groups effective October 1, 2022	English (Fillable PDF, 742 KB) Spanish (Fillable PDF, 721 KB)
	2022 Group Change Request New/renewing groups effective January 1, 2022	English (Fillable PDF, 1.17 MB) Spanish (Fillable PDF, 2.1 MB)
	2021 Group Change Request New/renewing groups effective October 1, 2021	English (Fillable PDF 2.9 MB) Spanish (Fillable PDF 2.3 MB)
	2021 Group Change Request New/renewing groups effective July 1, 2021	English (Fillable PDF 2.9 MB) Spanish (Fillable PDF 2.3 MB)
Multiple Subscriber Change Spreadsheet Submit subscriber-level enrollment changes.		Download (Fillable PDF)
Employee Cancellation Notification (formerly the Employee Change/Cancellation Transmittal) Use this form to terminate coverage for multiple employees. If applicable, use this form to provide notification of Cal-COBRA qualifying event due to termination, resignation, or reduction in employee hours.		Download (Fillable PDF)
Small Business Cancellation Form Use this form to cancel a group's coverage from Blue Shield for either Medical, Dental, Vision or Life		Download (Fillable PDF)
CMS Reporting Form Submit this form to Blue Shield of California to ensure that you are reporting employees who may have Medicare as the Primary Payer.		Download
Premium Only Plan (POP) HealthEquity POP allows premiums to be deducted on a pre-tax basis. Click download for informational flier and application.		Download

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Form		Download
Enrollment Spreadsheet		2023 - Q1 \| Q3 2022 - Q1 \| Q2 \| Q3 \| Q4
Guide to Enrollment Spreadsheet		Download
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. As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes.
	2023 Employee Application New/renewing groups effective July 1, 2023	English (Fillable PDF, 1.4 MB) Spanish (Fillable PDF, 1.6 MB)
	2023 Employee Application New/renewing groups effective January 1, 2023	English (Fillable PDF, 1.4 MB) Spanish (Fillable PDF, 1.6 MB)
	2022 Employee Application New/renewing groups effective October 1, 2022	English (Fillable PDF, 1.5 MB) Spanish (Fillable PDF, 876 KB)
	2022 Employee Application New/renewing groups effective January 1 through September 30, 2022	English (Fillable PDF, 1.23 MB) Spanish (Fillable PDF, 1.46 MB)
Subscriber Change Request Employees can change personal information, change plans during open enrollment, enroll new dependents, or cancel dependents (please include the Refusal or Cancellation of Personal Coverage form).
	2023 Subscriber Change Request New/renewing groups effective July 1, 2023	English (Fillable PDF, 1.3 MB) Spanish (Fillable PDF, 1.4 MB)
	2023 Subscriber Change Request New/renewing groups effective January 1, 2023	English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.4 MB)
	2022 Subscriber Change Request New/renewing groups effective October 1, 2022	English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.15 MB)
	2022 Subscriber Change Request New/renewing groups effective January 1 through September 30, 2022	English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.15 MB)
Refusal of Coverage Employees complete this form if they, their spouse/domestic partner, or other dependents refuse their employer’s medical or dental plan coverage
	2023 Refusal of Coverage form New/renewing groups effective July 1, 2023	English (Fillable PDF, 765 KB) Spanish (Fillable PDF, 881 KB)
	2023 Refusal of Coverage form New/renewing groups effective January 1, 2023	English (Fillable PDF, 764 KB) Spanish (Fillable PDF, 880 KB)
	2022 Refusal of Coverage form New/renewing groups effective October 1, 2022	English (Fillable PDF, 756 KB) Spanish (Fillable PDF, 876 KB)
	2022 Refusal of Coverage form New/renewing groups effective January 1, 2022	English (Fillable PDF, 567 KB)
Continuity of Care program brochure		English Spanish Chinese Vietnamese Hindi Korean
Request for Continuity of Care Service for established members and new enrollees Members of HMO-only groups with qualifying conditions may be able to complete care with a non-network provider.		English Spanish Chinese Vietnamese Hindi Korean
Authorization for the use or disclosure of health information		English Spanish Chinese Vietnamese Hindi Korean
Continuity of care notice for new HMO enrollees Important notice for new HMO enrollees.		Download
Declaration of Disability of Over-Age-Dependent Children For enrolled dependent children who normally lose their eligibility because of age but who have a physical or mental disabling injury.		English Spanish
Waiver of Premium Claim Form – Life If a member becomes totally disabled, the life premium may be waived.		Download
Premium Only Plan (POP) HealthEquity's POP lets employers cut payroll taxes without cutting payroll. If an employer requires employees to contribute to the cost of their insurance, a Section 125 POP allows them to do so with pre-tax dollars.		Download
CVS Mail Order Form		Download (Fillable PDF)

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Form	Download
Continuation of Coverage Application (COBRA and Cal-COBRA) For existing groups requesting effective dates of October 1, 2020, and later, this form replaces the "COBRA Continuation of Coverage Application”, the “Cal-COBRA Election”, the "Cal-COBRA Dental Election", and the “Continuing Group Coverage After Federal COBRA” forms. Use this form to apply for a continuation of coverage (federal COBRA or Cal-COBRA).	Download (Fillable PDF)
Employer Notification of Qualifying Events under Cal-COBRA This form replaces the “Employer Notification of Qualifying Events under Cal-COBRA (ENF)” form for groups requesting changes effective October 1, 2020, and later. Complete this form each time a covered employee has a qualifying event that causes them to be eligible for continuation coverage under the California Continuation Benefits Replacement Act (Cal-COBRA).	Download (Fillable PDF)
Cal-COBRA Take-Over New groups should use this form when changing carriers to Blue Shield for Cal-COBRA members covered under a previous carrier. Employers are responsible for notifying their Cal-COBRA members of the transition to a new carrier and Cal-COBRA members are required to fill out the form and submit it to the Cal-COBRA team within 30 days of transition.	Download (Fillable PDF)

Information on COBRA subsidies from the 2021 American Rescue Plan Act is available here.

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Form		Download
Subscriber's Statement of Claim		Download
American Specialty Health (ASH) – Subscriber Claim Form		Download
Out of State Claim Form		Download
Authorization for Release of Personal and Health Information		Download
Prescription Drug Reimbursement Form		English Spanish
Blue Shield Global Core International Claim		Download
Proof of Death Form: Group Life		Download
Accelerated Death Benefit Claim Form: Group Life		Download
Dismemberment Claim Form: Group Life		Download
Dental Claim		Download
Vision Claim		Download
Waiver of Premium Claim Form: Group Life If a member becomes totally disabled, the life premium may be waived.		Download
Beneficiary Affidavit & Assignment Form		Download
Beneficiary Change Request		Download

Form	Download
DOI	English \| Spanish
DMHC	English \| Spanish \| Chinese \| Hindi \| Vietnamese \| Korean

Form		Download
Conversion to Individual Coverage: Group Life		Download
Beneficiary Affidavit (life insurance groups of 10 or more)		Download
Beneficiary Change Request Form		Download

Forms and applications

Small Businesses (1 to 100)

Broker Resources

Options for application submissions

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