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Individuals & Families
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Forms and Applications
Individuals and Families

In our effort to provide you easier access to materials you need, we have consolidated all the forms and applications. We highly suggest that you enroll your clients through our Quote & Apply Tool for faster service times and commission payments; however, if you need a paper application for your client, we offer this "one-stop shop" page as an easy reference in order to continue providing excellent service to your clients.
Enrollment Updates
The 2017 open enrollment period for an individual to apply for coverage runs from November 1, 2016 through January 31, 2017. All eligible Californians will have the opportunity to purchase an individual and family plan during this three-month period with guaranteed acceptance. After January 31, 2017, consumers will not be able to enroll in a health plan until 2018 unless they experience a qualifying event.
Specialty Benefits
Dental  Life
Get an enrollment application for your clients who want to enroll in Blue Shield dental plan and vision coverage. Download the application for dental and vision plan and dental + vision Duo package.
English (PDF, 142KB)

Spanish (PDF, 151KB)

Chinese (PDF, 573KB)

Korean (PDF, 302KB)

Vietnamese (PDF, 145KB)
Application for Term Life Insurance Coverage (PDF, 291KB)

Evidence of Insurability (PDF, 482KB)
Use this form for clients who currently have life insurance through Blue Shield of California but want to increase their life benefit amount. Additional amounts of life insurance must be approved by the company.

Life Insurance Infographic Flier (PDF, 482KB)
Use this flier to help your clients understand the value of a Blue Shield life insurance coverage.

Acknowledgement of Life Insurance Replacement Coverage Form (PDF, 470KB)

Beneficiary Change Form  (PDF, 452KB)
Use this form to change a life insurance beneficiary.

Life Insurance Additional Contact Designation Form  (PDF, 1.06MB)
Claims Forms

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