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Forms and Applications
 
When providing an application to an applicant or Blue Shield member, you must also include a Notice of Language Assistance.

EmployerEmployeeClaimsContinuity of CareCOBRA/Cal-COBRA
Employer Forms and Applications
Fillable PDFs can be saved to your desktop. However, applicants using Acrobat Reader, rather than Acrobat Standard or Pro, will only be able to print the information after it's filled out, not save. If using Standard or Pro, If using Standard or Pro, the filled out information can be saved. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version.
Form   Download
Master Group Application
  Effective 1/1/2017
English (Fillable)
Spanish
Chinese
Vietnamese

Effective through 12/31/16
English (Fillable)
Spanish (Fillable)
Chinese (Fillable)
Vietnamese (Fillable)

Welcome letter and checklist
Use this customizable employer welcome letter and checklist to help simplify the enrollment process.
  Download (Fillable)
Subscriber Change Request
Employees can change personal information, change plans during open enrollment, enroll new dependents or cancel dependents (include Refusal or Cancellation of Personal Coverage form).
  English (Fillable)
Spanish (Fillable)
Employee Change/Cancellation Transmittal
Submit a monthly summary of employee cancellations and/or changes.
  Download
Group Information Update Form
Use this form to update a group's billing address or contact information.
  Download (Fillable)
Employer Questionnaire   Download (Fillable)
Employee Forms and Applications
Fillable PDFs can be saved to your desktop. However, applicants using Acrobat Reader, rather than Acrobat Standard or Pro, will only be able to print the information after it's filled out, not save. If using Standard or Pro, If using Standard or Pro, the filled out information can be saved. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version.
Form   Download
Employee Application
Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group.
   
Medical only
Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group.
  Effective 1/1/2017
English (Fillable)
Chinese (Fillable)
Spanish (Fillable)
Vietnamese (Fillable)

Effective through 12/31/16
English
Life only
Employees should complete this form to enroll in a group term life policy. For employee enrollments to a new or existing employer group.
  Effective 1/1/17
English (Fillable)
Spanish (Fillable)
Chinese (Fillable)
Vietnamese (Fillable)

Effective through 12/31/16
English
Spanish
Chinese
Vietnamese
 
Medical and Life
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.
  Effective 1/1/17
English (Fillable)
Spanish (Fillable)
Chinese (Fillable)
Vietnamese (Fillable)

Effective through 12/31/16
English
Employee applications for dental, vision and life plans for new and existing groups.   Download
Form   Download
HIPPAA Release Form
Authorization for the release of personal and health information.
  Download
Evidence of Insurability   Download 
Refusal of Personal Coverage Form
Employees should complete this form if they, their spouse/domestic partner of dependents are refusing their employer's medical or dental plan coverage.
  Download
Subscriber Disability
File for an extension of benefits. Administrators must also complete the Notice of Total and Permanent Disability Form.
  Download
Disability Addendum   Download
Specialty Benefits
Form   Download
Standalone Specialty Benefits Employer Application
Dental, Vision & Life Insurance
  Download
Dental Only Application   Download
Vision Only Application   Download 
Life Employee Application   Download 
Conversion to Individual Coverage: Group Life   Download 
Beneficiary Change: Group Life   Download 
Waiver of Premium Claim Form: Group Life
If a member becomes totally disabled, the life premium may be waived.
  Download 
Continuity of Care
Form   Download
Request for Continuity of Care Service for established members and new enrollees.   English*
Continuity of Care Notice
Important notice for new HMO enrollees
  English
Spanish
Chinese 
Vietnamese 
Claim Forms
Form   Download
Subscriber's Statement of Claim   Download 
Statement of Claim: Blue Shield Life   Download 
Authorization for Release of Personal and Health Information   Download 
Pharmacy Reimbursement   Download 
BlueCard WorldWide International Claim   Download 
Proof of Death Form: Group Life   Download 
Accelerated Death Benefit Claim Form: Group Life   Download 
Dismemberment Claim Form: Group Life   Download 
Dental Claim   Download 
Vision Claim   Download 
Waiver of Premium Claim Form: Group Life
If a member becomes totally disabled, the life premium may be waived.
  Download 
Cal-COBRA
Form   Download
COBRA Employee Application
  English
Spanish
Chinese
Vietnamese
Employer Notification of Qualifying Events under Cal-COBRA (ENF)
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
Cal-COBRA Take-Over
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 
Continuing Group Coverage after Federal COBRA Cal-COBRA Election
After exhausting 18 months of Federal COBRA benefits, a beneficiary may be eligible to 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 
Cal-COBRA Election
Once the employer submits the ENF, 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.
  Download 
Cal-COBRA Dental Election
For dental only groups: Once the employer submits the ENF, 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.
  Download 
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Additional Resources
Electronic enrollment
Benefit summaries
Benefit modifications for your renewing clients
Group administrator guide
Pulse Guide
TRUSTe Privacy Certification