Enrollment Forms

Small Businesses (1-100) | Large Groups (101+) | Cal-COBRA/COBRA

Complete fillable PDFs online and then print, sign and submit them to Blue Shield. You will need Adobe Reader to complete the fillable form. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version. We recommend using our online version where it is available.


Get additional forms:

Additions, changes and deletions | Claims

Small Businesses (1-100)

Form Purpose Download/
complete online

Master Group Application
(C15385)

This application includes a checklist of all the information and forms your broker will need in order to successfully submit your application.

2022 Application
Download PDF (English)1
(PDF, 856KB)

Download PDF (Spanish)1
(PDF, 637KB)

Employee Application
(C12914)

Employees should complete this application to enroll in a group medical plan, group vision plan, or group term life policy.

Log in to Employer Connection to enroll a new or existing employee.

2022 Application
Download PDF (English)1
(PDF, 1.2MB)

Download PDF (Spanish)1
(PDF, 1.2MB)

Disability Addendum
(C11248)

This form should accompany the new group application.

Download PDF
(PDF, 431KB)

HIPAA Release Form
(A46163)
This is an authorization for the release of personal and health information. Download PDF
(PDF, 127KB)
Medicare Advantage Prescription Drug Plans Enrollment Form (MG00001) This form is for Medicare-eligible retirees who want to enroll in Blue Shield 65 PlusSM, a group Medicare Advantage Prescription Drug plan. Download PDF
(PDF, 117KB)
Medicare Prescription Drug Plan Enrollment Form
(PDP00045)
This form is for retirees who want to enroll in Blue Shield of California Medicare Rx Plan (PDP), an Enhanced Group Prescription Drug Benefit plan. Download PDF
(PDF, 118KB)


Large Groups (101+)

Form Purpose Download/
complete online
Master Group Application
(C14939)

This application includes a checklist of all the information and forms your broker will need in order to successfully submit your application.

2022 Application

Download PDF (English)
(PDF, 1.8MB)
Download PDF (Spanish)
(PDF, 1.6MB)
Download PDF (Chinese)
(PDF, 2.2MB)
Download PDF (Vietnamese)
(PDF, 1.9MB)
Download PDF (Persian)
(PDF, 1.6MB)

Employee Application
(C15390)

Employees should complete this form to enroll in a group medical plan, group vision plan or group term life policy.

Log in to Employer Connection to enroll a new or existing employee

Log in to complete the application online

Employee Application
Medical only
(C15390-H)

Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group.

Download PDF (English)
(PDF, 1.4MB)
Download PDF (Spanish)
(PDF, 1.4MB)
Download PDF (Chinese)
(PDF, 1.8MB)
Download PDF (Vietnamese)
(PDF, 1.5MB)
Download PDF (Persian)
(PDF, 1.4MB)

Employee Application
Life only
(C15390-L)
Employees should complete this form to enroll in a group term life policy. For employee enrollments to a new or existing employer group.

Download PDF (English)
(PDF, 1.2MB)
Download PDF (Spanish)
(PDF, 1.2MB)
Download PDF (Chinese)
(PDF, 1.5MB)
Download PDF (Vietnamese)
(PDF, 1.3MB)
Download PDF (Persian)
(PDF, 1.2MB)

Employee Application
Medical and life
(C15390-HL)
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.

Download PDF (English)
(PDF, 1.4MB)
Download PDF (Spanish)
(PDF, 1.4MB)
Download PDF (Chinese)
(PDF, 1.8MB)
Download PDF (Vietnamese)
(PDF, 1.5MB)
Download PDF (Persian)
(PDF, 1.4MB)

Medicare Advantage Prescription Drug Plans Enrollment Form (MG00001) This form is for Medicare-eligible retirees who want to enroll in Blue Shield 65 PlusSM, a group Medicare Advantage Prescription Drug plan. Download PDF
(PDF, 117KB)
Medicare Prescription Drug Plan Enrollment Form
(PDP00045)
This form is for retirees who want to enroll in Blue Shield of California Medicare Rx Plan (PDP), an Enhanced Group Prescription Drug Benefit plan. Download PDF
(PDF, 118KB)
Disability Addendum
(C11248)
This form should accompany the new group application Download PDF
(PDF, 431KB)
HIPAA Release Form
(A46163)
This is an authorization for the release of personal and health information. Download PDF
(PDF, 127KB)

 


Cal-COBRA/COBRA

Form Purpose Download/
complete online
COBRA Application
(C11825-RTM)

If you are self administering or have a third party federal COBRA administrator and you have a qualified beneficiary electing to participate in COBRA, they must complete this application.

Log in to Employer Connection to enroll a new or existing employee

Log in to complete the application online

Download PDF (English)
(PDF, 457KB)
Downlaod PDF (Spanish)
(PDF, 91KB)
Download PDF (Chinese)
(PDF, 161KB)
Download PDF (Vietnamese)
(PDF, 178KB)

Employer Notification of Qualifying Events
Under Cal-COBRA
(C13140)
Complete this form when covered employees have an event that qualifies them for coverage under the California Continuation Benefits Replacement Act (Cal-COBRA, California Senate Bill 719).

Download PDF
(PDF, 134KB)

Cal-COBRA
Take-Over Form
(C14755)
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 fill out the form and submit to the Cal-COBRA team within 30 days of transition. Download PDF
(PDF, 75KB)
Continuing Group Coverage after FederalCOBRA
Cal-COBRA
Election Form
(C52299)

After exhausting 18 months of Federal COBRA benefits, a beneficiary may be eligible for an 18-month extension through Cal-COBRA. Beneficiary must contact Cal-COBRA (800-228-9476) to request the extension and ensure they meet the requirements. If approved, the beneficiary will submit this form to formally accept the extension.

Download PDF
(PDF, 1.5MB)

Cal-COBRA
Election Form
(C13141)

Once the employer submits the ENF (C13140), an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without employer first submitting the ENF (C13140).

Download PDF
(PDF, 113KB)

Cal-COBRA
Dental Election Form
(C18156)
For dental only groups: Once the employer submits the ENF (C13140), an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without employer first submitting the ENF (C13140). Download PDF
(PDF, 71KB)

1Complete fillable PDFs online and then print, sign and submit them to Blue Shield. You will need Adobe Reader to complete the fillable form. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version. We recommend using our online version where it is available.