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Forms and Applications
Small Businesses (1 to 100)

In our effort to provide you easier access to materials you need, we have consolidated all the small business forms and applications We hope that this "one-stop shop"  page will be an easy reference point for all your forms/application needs and will aid your effort to continue providing excellent service to your Small Business clients.
Fillable PDFs
Your groups can easily enter in information directly to the PDF. Once a fillable PDF is saved to the desktop, you cannot go back and make changes. 
Options for application submissions

Reminder: We no longer accept paper for many submissions.

Online – Option: the only option for many submissions (see exceptions below)

Exceptions for using our online system. Please use the applicable forms via fax or email for the following:
  • Specialty Benefits buy up and standalone coverage changes
  • COBRA and Cal-COBRA changes or additions (group and member level)
  • Add a second waiting period based on employee class
  • Changing domestic partner coverage (Narrow/Broad)
  • Employer contribution changes
  • Adding or removing part-time employee coverage
Email Option

Email to: Small.Group@blueshieldca.com.

Our members' security is important to us. To assure the secured transmittal of this data, we recommend that you use a secure e-mail system to transmit this required information.

Learn more about our secure email policy»
Fax Option
Fax: (855) 808-8598
Attention: Small Group Installation and Billing
Mailing Option
Blue Shield of California
Attn: Small Group Installation and Billing
P.O. Box 3008
Lodi, CA 95241-1912
Employer Forms and Applications (groups 1-100)
Form   Download
Master Group Application

As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes.
   
  2017 Master Group Application
New/renewing groups effective April 1, 2017 and after
  English (Fillable PDF)
  2017 Master Group Application
New/renewing groups effective January 1, 2017 through March 31, 2017
  English (Fillable PDF)
Spanish Fillable PDF)
  2016 Master Group Application
New/renewing groups effective October 1, 2016 through December 31, 2016
  English (Fillable PDF)
Spanish (Fillable PDF)
  2016 Master Group Application – Updated 4/8/16
New/renewing groups effective January 1, 2016 through Sepember 30, 2016
  English (Fillable PDF)
Spanish (Fillable PDF)
  2015 Master Group Application
New/renewing groups effective prior to January 1, 2016.
  English (Fillable PDF)
Spanish
Group Check-by-Fax Form
Use this form as another option to submit your cases. Be sure to complete the form and include your client's signature and a voided check.
  Download (Fillable PDF)
Sole Proprietor, Partner or Corporate Officer Statement Form
Use this form as proof of eligibility when owners are not listed on the DE9C.
  Download
Blue Shield of California Eligibility/Participation Attestation (for groups with 10+ enrolling employees)
Use this form for groups of 10+ for proof of eligibility.
  Download
Group Information Update Form
Use this form to update a Small Group's billing address or contact information.
  Download (Fillable PDF)
Small Business Plan Year/Contract Year Change Form
Use this form to notify Blue Shield of a small employer's change in group plan year, and to request an earlier renewal date for its contract to align coverage with its new plan year.
  Download
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)
   
  2017 Subscriber Change Request
New/renewing groups effective April 1, 2017 or after
English (Fillable PDF)
  2017 Subscriber Change Request
New/renewing groups effective January 1, 2017 through March 31, 2017
English (Fillable PDF)
Spanish Fillable PDF)
  2016 Subscriber Change Request – Updated 12/18/2015
New/renewing groups effective January 1, 2016 through December 31, 2016
English
Spanish
  2015 Subscriber Change Request
New/renewing groups effective prior to January 1, 2016
English (Fillable PDF)
Spanish
Request for Contract Change
Visit Online Renewals to submit changes, except for: Specialty Benefits buy up for life insurance and coverage changes or plan additions for standalone Specialty Benefits (dental, vision, or life insurance only with no medical) coverage.**
   
  2017 Request for Contract Change
New/renewing groups effective April 1, 2017 or after
English (Fillable PDF)
  2017 Request for Contract Change
New/renewing groups effective January 1, 2017 through March 31, 2017
English (Fillable PDF)
Spanish Fillable PDF)
  2016 Request for Contract Change
New/renewing groups effective October 1, 2016 through December 31, 2016
English (Fillable PDF)
Spanish (Fillable PDF)
  2016 Request for Contract Change – Updated 4/8/2016
New/renewing groups effective January 1, 2016 through September 30, 2016
English (Fillable PDF)
Spanish (Fillable PDF)
  2015 Request for Contract Change
New/renewing groups effective prior to January 1, 2016.
English
Spanish
Employee Change/Cancellation Transmittal
Submit a monthly summary of employee cancellations and/or changes.
  Download 
CMS Reporting Form
Submit this form to Blue Shield of California to ensure that you are reporting employees who may have Medicare as the Primary Payer.
  Download 
 
Employee Forms and Applications (groups 1-100)
Form   Download
Employee Application
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.

As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes. 
   
  2017 Employee Application
New/renewing groups effective April 1, 2017 or after
  English (Fillable PDF)
  2017 Employee Application
New/renewing groups effective January 1, 2017 through March 31, 2017
  English (Fillable PDF)
Spanish (Fillable PDF)
  2016 Employee Application – Updated 12/18/2015
New/renewing groups effective January 1, 2016 through December 31, 2016
  English (Fillable PDF)
Spanish (Fillable PDF)
  2015 Employee Application
New/renewing groups effective prior to January 1, 2016
  English (Fillable PDF)
Spanish
Refusal of Coverage
Employees complete this form if they, their spouse/domestic partner of dependents are refusing their employer’s medical or dental plan coverage.
  Download (Fillable PDF)
Request for Continuity of Care Service for established members and new enrollees
Members of HMO-only groups with qualifying conditions may be able to complete care with a non-network provider.
  Download
Continuity of care notice for new HMO enrollees
Important notice for new HMO enrollees.
  Download
Declaration of Disability of Over Age Dependent Children
For enrolled dependent children who normally lose their eligibility because of age, but who are disabled by reason of a physically or mentally disabling injury.
  Download
Waiver of Premium Claim Form – Life
If a member becomes totally disabled, the life premium may be waived.
  Download 
Premium Only Plan (POP)
The premium only plan lets employers cut payroll taxes without cutting payroll. If an employer requires employees to contribute to the cost of their insurance a Section 125 Premium Only Plan (POP) allows them to do so with pre-tax dollars. For a check list on whether your client qualifies for POP along with an application, download this informational brochure.
  Download 
Specialty Benefits
Form   Download
Employer Application
For employer applications, please use the Master Group Application
   
    2017 Employee Application
    New/renewing groups effective April 1, 2017 or after
  English (Fillable PDF)
    2017 Employee Application
    New/renewing groups effective January 1, 2017 through March 31, 2017
  English(Fillable PDF)
Spanish
   2016 Employee Application
    New/renewing groups effective January 1, 2016 through December 31, 2016
  English (Fillable PDF)
Spanish (Fillable PDF)
    2015 Employee Application
    New/renewing groups effective prior to January 1, 2016
  English (Fillable PDF)
English
Conversion to Individual Coverage: Group Life   Download 
Beneficiary Affidavit (life insurance groups of 10 or more)   Download
Claims
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
 
COBRA and CAL-COBRA
Form   Download
COBRA Employee Application
  Download
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 
*Translations temporarily unavailable.
**Underwritten by Blue Shield of California Life & Health Insurance Company.
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