Please complete these 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, you can download the latest Adobe Reader version. We recommend using our online version where available.
Small Businesses (1-100)
| Form | Purpose | Download/ complete online |
|---|---|---|
Master Group application |
This application includes a checklist of all the information and forms your broker will need to successfully submit your application. |
2027 Application 2026 Application |
| 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. |
2027 Application 2026 Application |
| Disability addendum (C11248) |
This form should accompany the new group application. |
English (PDF, 431 KB) |
| HIPAA release form (A46163) |
This is an authorization for the release of personal and health information. | English (PDF, 127 KB) |
| 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. | English (PDF, 117 KB) |
| Medicare Prescription Drug Plan enrollment form (PDP00045) |
This form is for retirees who want to enroll in Blue Shield of California's Medicare Rx Plan (PDP), an Enhanced Group Prescription Drug Benefit plan. | English (PDF, 118 KB) |
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 to successfully submit your application. |
2027 Application English (PDF, 2.2 MB) 2026 Application English (PDF, 1.5 MB) |
| 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 |
|
| Employee application Medical only (C15390-H) |
Employees should complete this form to enroll in a group medical plan. This form is for employee enrollments into a new or existing employer group. |
2027 Application English (PDF, 484 KB) 2026 Application English (PDF, 484 KB)
|
| Employee application Life only (C15390-L) |
Employees should complete this form to enroll in a group term life policy. This form is for employee enrollments into a new or existing employer group. | 2027 Application English (PDF, 452 KB) 2025 Application English (PDF, 452 KB) |
| 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. This form is for employee enrollments into a new or existing employer group. | 2027 Application English (PDF, 1.0 MB) 2026 Application English (PDF, 1.0 MB)
|
| 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. | English (PDF, 117 KB) |
| 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. | English (PDF, 118 KB) |
| Disability addendum (C11248) |
This form should accompany the new group application | English (PDF, 431 KB) |
| HIPAA release form (A46163) |
This is an authorization for the release of personal and health information. | English (PDF, 127 KB) |
Cal-COBRA/COBRA
| Form | Purpose | Download/ complete online |
|---|---|---|
| COBRA Application (C11825-RTM) |
Complete this form if you are self-administering group or you have a third-party federal COBRA administrator. If you have a qualified beneficiary electing to participate in COBRA, then they must complete this application. Log in to Employer Connection to enroll a new or existing employee |
|
| 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 |
| Cal-COBRA Take-Over Form (C14755) |
New groups should use this form when Cal-COBRA members are changing carriers to Blue Shield. 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 and submit the form to the Cal-COBRA team within 30 days of transition. | Download PDF (PDF, 75 KB) |
| 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 |
| Cal-COBRA Election Form (C13141) |
Once the employer submits the Employer Notification Form, or ENF (C13140), an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and their plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without the employer first submitting the ENF (C13140). |
Download PDF |
| 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 their 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, 71 KB) |
W-9s and other IRS forms
Blue Shield of California plans: Download W-9 (PDF, 548 KB)
Blue Shield of California Life & Health Insurance Company plans: Download W-9 (PDF, 544 KB)
Not sure which form to use? Give us a call at (800) 325-5166.
We update these forms often, but still advise that you check the IRS website to make sure you have the most recent W-9s. You can also find the tax forms you need.