Employer Forms and Applications (groups 1-100)

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
Small Group Broker of Record Change Request		Download

Employer Forms and Applications (groups 1-100)

Form

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