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Blue Cross of California
Plans for Businesses with 2-50 People Six Steps to Enrollment: Our goal is to expedite the handling of your new group. In order to provide prompt processing of your application, the following new group submission steps outline the insurance carrier’s requirements for enrollment. Please complete and submit the following in their entirety as incomplete forms or missing information may result in a later effective date than requested. You will be able to print and email forms. Please use a pen to complete all forms. Click here for Blue Cross Group Eligibility Summary information.
Please submit completed documents to: Quote Health Insurance Agency
849 Almar Street, Suite C 283
Santa Cruz, CA 95060-6262
Questions? Email us or call: (831) 426-4000 Fax: (831) 426-6453
PLEASE KEEP A COPY OF THE APPLICATIONS FOR YOUR RECORDS
Step One:
If your company is newly enrolling with Blue Cross, please proceed to step two. If your company is a current Blue Cross member and would like to change plan options and/or brokers, please complete the Agent Appointment Form. Step Two: EmployeeElect Portfolio: Complete Small Group Employer Application EmployeeChoice Portfolio: same enrollment forms as EmployeeElect are used. Employer to write in “EmployeeChoice” in the Other box in Section 2a and write in "EmployeeChoice” on the adjacent line.
If applicable, for groups enrolling 2-24 employees one of the following: Cal-COBRA/COBRA/FMLA Questionnaire (included in the Employer Application), or submit the last billing statement listing COBRA/Cal-COBRA subscribers.
Please note: It is the Employer’s responsibility to contact their prior carrier to verify CalCOBRA or COBRA participants as an application and premium for each enrollee is required.
Step Three:
Group Employee Applications (also available in Spanish, Korean, Chinese, and from all employee/dependents enrolling (employee’s signature date cannot be more than 60 days prior to the requested effective date of the new group. If older than 60 days, an Exceptions to Standard Enrollment/Translator’s Statement may be submitted.) Only the employee may fill in, or modify information filled in, on the employee application. Any changes to the filled in information must be initialed and dated by the employee. Included in the Employee application is a health questionnaire*. Please note: Groups of 2-10 enrolling employees, complete the long form health questions
Groups of 11-14 enrolling employees, complete the short form health questions
Groups of 15-50 enrolling employees have the option of answering health questions or receiving up to a possible 10% premium rate discount.
In addition to the employee application, when applicable, a completed Affidavit of Domestic Partner.
Step 4
Please provide your most recent company DE-6 Quarterly State Tax Withholding Statement with the status of all employees listed (e.g. terminated, waiving coverage, etc.)
If the group has not been in business long enough to provide a DE-6 or a 30 days payroll, the Conditions of Enrollment for Start-Up Groups will be required. A completed Sole Proprietors, Partners and Corporate Officers Statement for those not appearing on the DE-6 quarterly wage report.
Step 5
A company check for 100% of the first month’s Medical, Dental, Life, and/or Vision premiums made payable to Blue Cross of California
Step Six
If group has current coverage ( donnot cancel your old insurance until your new policy is approved), please provide a copy of the last month’s group premium statement.
Optional Enrollment Materials:
H.S.A.-Compatible Plans • Same enrollment forms as EmployeeElect. In addition, the employer must complete and submit the "Employers Statement of Understanding" form.
• If the employer elects to offer the High Deductible HSA-Compatible plan with enrollment through JP Morgan/Chase, they must submit a completed original Chase Health Savings Account Employer Group H.S.A. Initiation Form (form #SC11963)
• If the employee selects to enroll in the H.S.A. with JP Morgan/Chase, they must submit a completed, original Chase Health Savings Account Application (form #SC11962) along with their Blue Cross employee application
Optional: Premium Only Plan (P.O.P.)
to be submitted at the same time as medical (and life if applicable) enrollment paperwork:
• Complete the Employer’s Guide to P.O.P. application (form #3949)
• Submit a separate company check for $125 made payable to Blue Cross of California
HMO Application
PPO Application
Senior HMO Application
Senior PPO Application
SmileNet Application
Applications/Forms/Rates 2-50 Small Group Employer Application
Ceridian FSA/COBRA Services Flier Ceridian COBRA Proposal Employer Group HSA Initiation Form Group Participant Enrollment Package HSA Employer's Statement of Understanding HSA Premium Only Plan Enrollment Form
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�� Sole Proprietor: Schedule C (a California Business License or Fictitious Business name filing is acceptable only if the owner has not filed a Schedule C due to an extension to file or length of time in business). Corporations: Statement by Domestic Stock (certified by the Secretary of State) or Articles of Incorporation (filed and endorsed listing names of all officers) Limited Liability Corporation (LLC): Articles of Organization with Operating Agreement or Statement of Information (certified by the Secretary of State) and Schedule K-1 for each partner Partnership, Limited Partnership (LP), Limited Liability Partnership (LLP): Schedule K-1 for each partner
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Groups of 2-10 enrolling employees complete the long form health questions
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�� Please note: If choosing an H.S.A.-Compatible plan the EPO plan cannot be supported through the Blue Cross partnership with Chase. You should contact Chase directly or another institution that offers H.S.A. arrangements
PLEASE KEEP A COPY OF THE APPLICATIONS FOR YOUR RECORDS to health insurance for Employer groups with 2-50 employees |
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Blue Shield of California
Plans for Businesses with 2-50 People Applications/Forms/Rates Master Group Application Employee Application Refusal of Personal Coverage Change Request Form Employer Questionnaire (2-14) Employer Questionnaire (15-50) Sole Proprietor, Partner, or Corporate Officer Statement Statement of Domestic Partnership Conversion to Individual Coverage Form Subscriber Disability Form Eligibility Change Form Subscribers Statement of Claim COBRA Application Cal COBRA Takeover Form Direct Reimbursement Claim Full Time Student Certification International Claim Form Plans for Individuals and Families Applications/Forms/Rates Online Application Application Temporary Health Plans Option One Applicaton Option Twelve Application Plans for Seniors with Mediare Part A and B Applications/Forms/Rates Applicaton Blue Shield Dental, Vision & Life Plans for Businesses with 2-50 People Applications/Forms/Rates Health & Joint Dental Employer Application Health & Joint Dental Employee Application Dental Stand Alone Employer Application Dental Stand Alone Employee Application Blue Shield Vision Stand-Alone Group Vision Application Employee Vision Enrollment Form Blue Shield Life Stand-Alone Group Life Application Employee Life Enrollment Form Dental plans for Individuals and Families Applications/Forms/Rates Application |
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Delta Dental
Plans for Businesses with 2-50 People Delta Dental Employer Application Employee Application Declination of Dental Coverage Delta Dental - Elan Trust Employee Application Declination of Dental Coverage DeltaCare Employer Application Employee Application DeltaCare - Elan Trust Employee Application Declination of Dental Coverage Applications/Forms/Rates DENTAL PLANS FOR INDIVIDUALS AND FAMILIES Application/Forms/Rates Application Senior Application |
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Kaiser Permanente
Plans for Businesses with 2-50 People Kaiser Permanente Choice Solution Employer Application Employee Application Employee Health Questionnaire Owner/Partner Statement Cobra Enrollment Change Request Form Cobra Billing Direct Underwriting Guidelines Applications/Forms/Rates Plans for Individuals and Families Applications/Forms/Rates Plans for Seniors with Mediare Part A and B Applications/Forms/Rates Kaiser Permanente Choice Solution Dental Employer Application Employee Application |
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Health Net
Plans for Businesses with 2-50 People Applications/Forms/Rates Small Business Plans Group Service Agreement Small Business Employee Enrollment Form Small Business Employee Enrollment Form - Spanish Affidavit of Domestic Partnership Health Questionnaire Health Questionnaire (Spanish) Health Net HnOptions Employer Application Employee Application Kaiser Permanente Employee Enrollment Application New Group Application Student Certification Domestic Partner Affidavit Employee Enrollment Application (Spanish) Declination of Coverage COBRA Enrollment Form COBRA Information Sheet Proprietor Partnership Form Account Change Form Termination and Transfer Form Plans for Individuals and Families Applications/Forms/Rates Online Application
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PacifiCare
Plans for Businesses with 2-50 People Applications/Forms/Rates Prescription Mail Order Employee Enrollment and Declination of Coverage Form Group Acceptance/Change Form (GAF) Change Request Form COBRA Election Form Cal-COBRA Election Form Cal-COBRA Event Form POS Medical Claim Form Small Group Employer Application and Questionnaire Small Business Individual Health Statement Application Proprietor Statement Self Directed Health Plan Claim Form Employer Group Reporting Form PPO-Indemnity Medical Claim Form Student Status Declination of Coverage Domestic Partnership HIPAA Member Authorization Spanish Employer Application Spanish Employee Enrollroment Spanish Employee Change Request Spanish Employer Cobra Election Form Spanish Health Statement Plans for Individuals and Families Applications/Forms/Rates HMO Application PPO Application
Plans for Seniors with Medicare Part A and B Applications/Forms/Rates Application PacifiCare Dental and Vision Plans for Businesses with 2-50 People Dental Employee Enrollment Form Dental Employer Enrollment Form Employee Declination of Coverage Form PacifiCare Group Vision Vision Employee Enrollment Form Vision Employer Enrollment Form |
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Health Net of California
Application
MediCare Plans
Blue Cross of California
Blue Shield
Application
Health Net of California
Application
Part D Application
Dental Plans
Blue Cross of California
Blue Shield
Application
DeltaDental
Application
Senior Application
Kaiser Permanente California
Application
PacifiCare of California
Application
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Some forms, where noted, can easily be completed online. For all others, please use the appropriate form below.
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