Employer Forms and Applications (groups 1-100)

Employer Forms and Applications (groups 1-100)

Form

 

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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
2022 - Q4
2022 - Q1 / Q2 / Q3

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 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 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) 
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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    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.