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* Individual & Family
* LOG IN FOR ACCESS
* View all submitted applications
* Access client list
* Start enrollment
* Broker training webinars
* News & announcements
* PUBLIC LINKS
* Individual & Family Home
* Medical plans
* Dental plans
* Vision plans
* Life plans
* * Sales collateral
* Forms & applications
* Client notifications
* Tools & Resources
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* Individual & Family
* LOG IN FOR ACCESS
* View all submitted applications
* Access client list
* Start enrollment
* Broker training webinars
* News & announcements
* PUBLIC LINKS
* Individual & Family Home
* Medical plans
* Dental plans
* Vision plans
* Life plans
* * Sales collateral
* Forms & applications
* Client notifications
* Tools & Resources
* Contact sales & support offices
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* LOG IN FOR ACCESS
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* View application status
* News & FAQs
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* Small Business
* LOG IN FOR ACCESS
* Shop & enroll
* New group submission status
* View client list
* Online renewal
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* Employer Connection
* Renewal and post enrollment packets
* News & announcements
* PUBLIC LINKS
* Small Business home
* Medical plans
* Dental plans
* Vision plans
* Life and AD&D plans
* Plan and network comparison tools
* * Sales collateral
* Forms & applications
* Product Cycle updates
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* Contact sales and support offices
* Resources for our Brokers
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* LOG IN FOR ACCESS
* Administer member level changes
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* Post enrollment packets
* News & announcements
* PUBLIC LINKS
* Large Group home
* Medical plans
* Dental plans
* Vision plans
* Life and AD&D plans
* Plan and network comparison tools
* * Sales collateral
* Forms & applications
* Tools & Resources
* Contact sales and support offices
* Resources
* LOG IN FOR ACCESS
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* Advertising & marketing resources
* Order materials
* Update your profile
* Direct deposit
* Manage your accounts
* * Rewards & commissions
* Mandates information
* Personalize your website
* Email Producer Services
* Broker communications
* Broker of Record Change
* PUBLIC LINKS
* Quick links for Brokers
* Tools & Resources
* Find a Doctor
* Pharmacy
* Health & wellness
* Contact us
* Be a Blue Shield of CA Broker
1. Broker
2. Small Business
3. Small Business Resources
1. Small Business
SMALL BUSINESS FORMS AND APPLICATIONS
SMALL BUSINESSES (1 TO 100)
In our effort to provide easier access to the 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.
OPTIONS FOR APPLICATION SUBMISSIONS
Online submissions are the preferred option for many submissions (see exceptions
below):
* For group renewal change submissions, please visit Online Renewals.
* For group renewal changes for November 2024 and beyond, use EET Renewals.
* When advised for Special Enrollment Periods.
The Employer Enrollment Tool supports Small Group quoting, new group enrollment,
and group-level and member-level changes, with no need to submit a paper form.
The Employer Enrollment Tool does not support the following, and therefore the
appropriate paper form will need to be submitted:
* Enrollment of subscribers without a Social Security Number
* Enrollment of court-ordered dependents as subscribers
* Cal-Cobra changes or management
* Reinstating an employer group
Email
Small.Group@blueshieldca.com
Our members' security is important to us. To assure the secure transmittal of
this data, we recommend that you use a secure email system to transmit this
required information.
Fax
(855) 808-8598
Attention: Small Group Installation and Billing
Mail
Blue Shield of California
Attn: Small Group Installation and Billing
P.O. Box 3008, Lodi, CA 95241-1912
Note: to download a form, go to "Print", select "Save as PDF," and click "Save"
* Broker resources
* 2025 Summary of Benefits (SOB)
* 2024 Summary of Benefits (SOB)
* 2023 Summary of Benefits (SOB)
* Rates
* Renewal center
* Evidence of Coverage (EOCs)
* Changes to document(s)
* Underwriting guidelines
* Sales resources and collateral
* Document library
* Small Business Producer of Record form
EMPLOYER FORMS AND APPLICATIONS (GROUPS 1-100)
Form Download
Enrollment spreadsheet with master group application
Use this form to submit both the Employee Enrollment Applications and Master
Group Application in one integrated document.
As a reminder, you must use the Enrollment Spreadsheet for your Employee
Enrollment application if you submit the Master Group Application through this
document.
Refer to the Enrollment Spreadsheet Guide in the Employee forms and applications
section below.
2025- Q1
2024 – Q1 | Q3 | Q4
2023 – Q1 | Q3
2022 – Q1 | Q2 | Q3 | Q4
MASTER GROUP APPLICATION
AS A REMINDER, ONCE A FILLABLE PDF IS SAVED TO THE DESKTOP, YOU CANNOT GO BACK
AND MAKE CHANGES.
2025 Master group application
New/renewing groups effective January 1, 2025
English (Fillable PDF, 444 KB)
Spanish (Fillable PDF, 432 KB)
2024 Master group application
New/renewing groups effective July 1, 2024
English (Fillable PDF, 409 KB)
Spanish (Fillable PDF, 366 KB)
2024 Master group application
New/renewing groups effective January 1, 2024
English (Fillable PDF, 648KB)
Spanish (Fillable PDF, 643KB)
2023 Master group application
New/renewing groups effective July 1, 2023
English (Fillable PDF, 644KB)
Spanish (Fillable PDF, 769KB)
2023 Master group application
New/renewing groups effective January 1, 2023
English (Fillable PDF, 714KB)
Spanish (Fillable PDF, 736KB)
2022 Master group application
New/renewing groups effective October 1, 2022
English (Fillable PDF, 751KB)
Spanish (Fillable PDF 677KB) Small group initial payment form
Use this form as another option to submit your cases. Be sure to complete the
form and include your client's signature. Download (Fillable PDF, 73 KB) Small
group start-up/spin-off eligibility statement
Use this form for start-up and spin-off groups to attest for eligibility.
Download (Fillable PDF, 520 KB) Small group owner eligibility statement
Use this form for owners to attest for eligibility. Download (Fillable PDF, 492
KB)
GROUP CHANGE REQUEST
THIS FORM REPLACES THE “REQUEST FOR CONTRACT CHANGE”, THE “GROUP INFORMATION
UPDATE” AND THE “GROUP NAME CHANGE” FORMS FOR GROUPS REQUESTING CHANGES
EFFECTIVE OCTOBER 1, 2020 AND LATER. USE THIS FORM TO CHANGE COMPANY
INFORMATION, CONTACTS, GROUP ELECTIONS, OR PLANS.
2025 Group change request
New/renewing groups effective January 1, 2025
English (Fillable PDF, 468 KB)
Spanish (Fillable PDF, 458KB)
2024 Group change request
New/renewing groups effective July 1, 2024
English (Fillable PDF, 440 KB)
Spanish (Fillable PDF, 436 KB)
2023 Group change request
New/renewing groups effective January 1, 2024
English (Fillable PDF, 664KB)
Spanish (Fillable PDF, 657KB)
2023 Group change request
New/renewing groups effective July 1, 2023
English (Fillable PDF, 724KB)
Spanish (Fillable PDF, 635KB)
2023 Group change request
New/renewing groups effective January 1, 2023
English (Fillable PDF, 672KB)
Spanish (Fillable PDF, 714KB)
2022 Group change request
New/renewing groups effective October 1, 2022
English (Fillable PDF, 742KB)
Spanish (Fillable PDF, 721KB) Multiple subscriber change spreadsheet
Submit subscriber-level enrollment changes. Download (Fillable PDF, 83 KB)
Employee cancellation notification (formerly the employee change/cancellation
transmittal)
Use this form to terminate coverage for multiple employees. If applicable, use
this form to provide notification of Cal-COBRA qualifying event due to
termination, resignation, or reduction in employee hours. Download (Fillable
PDF, 1.2 MB) Small business cancellation form
Use this form to cancel a group's coverage from Blue Shield for either Medical,
Dental, Vision or Life Download (Fillable PDF, 635 KB) 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 Premium only plan
(POP)
HealthEquity POP allows premiums to be deducted on a pre-tax basis. Click
download for informational flyer and application. Download Small group broker of
record change request Download
EMPLOYEE FORMS AND APPLICATIONS, INCLUDING ENROLLMENT SPREADSHEET TOOL (GROUPS
1-100)
Form Download
Enrollment spreadsheet
Enrollment Spreadsheet Guide- 2025 | 2024
2025 - Q1
2024 - Q1 | Q3 | Q4
2023 - Q1 | Q3
2022 - Q1 | Q2 | Q3 | Q4
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.
2025 Employee application
New/renewing groups effective January 1, 2025
English (Fillable PDF, 1.3 MB)
Spanish (Fillable PDF, 1.3 MB)
2024 Employee application
New/renewing groups effective July 1, 2024
English (Fillable PDF, 1.2 MB)
Spanish (Fillable PDF, 1.2 MB)
2024 Employee application
New/renewing groups effective January 1, 2024
English (Fillable PDF, 1.5MB)
Spanish (Fillable PDF, 1.5MB)
2023 Employee application
New/renewing groups effective July 1, 2023
English (Fillable PDF, 1.4MB)
Spanish (Fillable PDF, 1.6MB)
2023 Employee application
New/renewing groups effective January 1, 2023
English (Fillable PDF, 1.4MB)
Spanish (Fillable PDF, 1.6MB)
2022 Employee application
New/renewing groups effective October 1, 2022
English (Fillable PDF, 1.23MB)
Spanish (Fillable PDF, 1.46MB)
SUBSCRIBER CHANGE REQUEST
EMPLOYEES CAN CHANGE PERSONAL INFORMATION, CHANGE PLANS DURING OPEN ENROLLMENT,
ENROLL NEW DEPENDENTS, OR CANCEL DEPENDENTS (PLEASE INCLUDE THE REFUSAL OR
CANCELLATION OF PERSONAL COVERAGE FORM).
2025 Subscriber change request
New/renewing groups effective January 1, 2025
English (Fillable PDF, 533 KB)
Spanish (Fillable PDF, 626 KB)
2024 Subscriber change request
New/renewing groups effective July 1, 2024
English (Fillable PDF, 1.1 MB)
Spanish (Fillable PDF, 1.2 MB)
2024 Subscriber change request
New/renewing groups effective January 1, 2024
English (Fillable PDF, 1.3MB)
Spanish (Fillable PDF, 1.4MB)
2023 Subscriber change request
New/renewing groups effective July 1, 2023
English (Fillable PDF, 1.3MB)
Spanish (Fillable PDF, 1.4MB)
2023 Subscriber change request
New/renewing groups effective January 1, 2023
English (Fillable PDF, 1.2MB)
Spanish (Fillable PDF, 1.4MB)
2022 Subscriber change request
New/renewing groups effective October 1, 2022
English (Fillable PDF, 1.2MB)
Spanish (Fillable PDF, 1.15MB)
REFUSAL OF COVERAGE
EMPLOYEES COMPLETE THIS FORM IF THEY, THEIR SPOUSE/DOMESTIC PARTNER, OR OTHER
DEPENDENTS REFUSE THEIR EMPLOYER’S MEDICAL OR DENTAL PLAN COVERAGE
Refusal of coverage form
English (Fillable PDF, 556 KB)
Spanish (Fillable PDF, 674 KB) Continuity of care program brochure English
Spanish
Chinese
Vietnamese
Hindi
Korean 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. English
Spanish
Chinese
Vietnamese
Hindi
Korean Authorization for the use or disclosure of health information English
Spanish
Chinese
Vietnamese
Hindi
Korean Declaration of disability of over-age-dependent children
For enrolled dependent children who normally lose their eligibility because of
age but who have a physical or mental disabling injury. English
Spanish Waiver of premium claim form – life
If a member becomes totally disabled, the life premium may be waived. Download
Premium only plan (POP)
HealthEquity's POP lets employers cut payroll taxes without cutting payroll. If
an employer requires employees to contribute to the cost of their insurance, a
Section 125 POP allows them to do so with pre-tax dollars. Download CVS mail
order form Download
COBRA AND CAL-COBRA
Form Download Continuation of Coverage Application (COBRA and Cal-COBRA)
For existing groups requesting effective dates of October 1, 2020, and later,
this form replaces the "COBRA Continuation of Coverage Application”, the
“Cal-COBRA Election”, the "Cal-COBRA Dental Election", and the “Continuing Group
Coverage After Federal COBRA” forms. Use this form to apply for a continuation
of coverage (federal COBRA or Cal-COBRA).
Download (Fillable PDF)
Employer Notification of Qualifying Events under Cal-COBRA
This form replaces the “Employer Notification of Qualifying Events under
Cal-COBRA (ENF)” form for groups requesting changes effective October 1, 2020,
and later. Complete this form each time a covered employee has a qualifying
event that causes them to be eligible for continuation coverage under
the California Continuation Benefits Replacement Act (Cal-COBRA).
Download (Fillable PDF)
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 to fill out the form and submit it to the
Cal-COBRA team within 30 days of transition. Download (Fillable PDF)
Cal-COBRA Election form
This form is for members to enroll in Cal-COBRA is they have exhausted their
Federal Cal-COBRA coverage, are not eligible for Federal Cal-COBRA coverage due
to their employer's type of coverage, or are moving from another carrier's
Cal-COBRA policy to a Cal-COBRA policy under Blue Shield.
Download (Fillable PDF)
CLAIMS
Form Download Subscriber's Statement of Claim Download American Specialty Health
(ASH) – Subscriber Claim form Download Out of State Claim form (Travel
Reimbursement) Download Out of State Claim form Download Authorization for
Release of Personal and Health Information Download Prescription Drug
Reimbursement form English
Spanish Blue Shield Global Core 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
Beneficiary Affidavit & Assignment form Download Beneficiary Change Request
English
Spanish
SPECIALTY BENEFITS
Form Download Conversion to Individual Coverage: Group Life
Download
Beneficiary Affidavit (life insurance groups of 10 or more)
Download
Beneficiary Change Request form Download Additional Contact Designation form:
Notice of Lapse or Termination of Life Insurance Policy for Non-Payment of
Premium Download
NOTICE INFORMING INDIVIDUALS ABOUT NONDISCRIMINATION AND ACCESSIBILITY
REQUIREMENTS
Form Download DOI
English
Spanish
DMHC
English
Spanish
Chinese
Hindi
Vietnamese
Korean
*Translations temporarily unavailable.
**Underwritten by Blue Shield of California Life & Health Insurance Company.
CONTACT US – PHONE
* Producer Services (800) 559-5905
* Employer Services (800) 325-5166
CONTACT US – MAIL
* Blue Shield of California
* PO Box 272540
* Chico, CA 95927-2540
QUICK LINKS
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© California Physicians' Service DBA Blue Shield of California 1999-2024. All
rights reserved. California Physicians’ Service DBA Blue Shield of California is
an independent member of the Blue Shield Association. Health insurance products
are offered by Blue Shield of California Life & Health Insurance Company. Health
plans are offered by Blue Shield of California.
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