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Enrollment Forms
Individual and Family Plans

Important Enrollment Update
The initial open enrollment period for an individual to apply for a new ACA-compliant plan runs from October 1, 2013 through March 31, 2014. All eligible Californians will have the opportunity to purchase an individual and family plan during this six-month period with guaranteed acceptance. And you will have an historic opportunity to capture the influx of new consumers entering the market. Please note: All applications for a 2014 health plan must be submitted online through our Quote & Apply tool – paper applications will no longer be available – or through Covered California. Learn more»

MEDICAL
Application

Download English:

 3-person application (PDF, 710KB)

 6-person application (PDF, 940KB)
 
Download Spanish (PDF, 3MB)
Download Chinese (PDF, 1MB)
Download Vietnamese (PDF, 905KB)
Plan Change/Transfer Forms
Important update: please use fax number (888) 386-3420 when submitting this form.
Download English (PDF, 125KB)
Download Spanish (PDF, 164KB)
Download Chinese (PDF, 369KB)
Download Vietnamese (PDF, 272KB) 
IFP Plan Transfer Matrix
You can download the IFP Plan Transfer Matrix to determine your clients' free transfer options.

 Download (PDF, 315KB) – Revised August 27, 2012
DENTAL AND LIFE
Dental
Get an enrollment application for your clients who want to enroll in Blue Shield dental plan coverage.

Dental plan and dental + vision package enrollment application – English (PDF, 172KB)
Life

Evidence of Insurability (CP1021-IND (10/09), PDF, 482KB)
Clients must submit this form if they apply for life coverage after they have already enrolled in a health plan.
Acknowledgement of Life Insurance Replacement Coverage form (PDF, 470KB)
Automatic Payment Option

IFP Easy$Pay Form (PDF, 528KB)
Download an authorization form to enroll your clients in convenient, automatic payments of their dues/premium.
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