Employee Forms and Applications incl. Enrollment Tool (groups 1-100)

Employee Forms and Applications, including Enrollment Spreadsheet Tool (groups 1-100)

Form

 

Download

Enrollment Spreadsheet

 

2023 - Q1
2022 - Q4
2022 - Q1 / Q2 / Q3
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 January 1, 2023
  English (Fillable PDF, 1.4 MB)
Spanish (Fillable PDF, 1.6 M
B) 
  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 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 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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Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.