BLUE SHIELD OF CALIFORNIA
Employer Group Application
Employee Enrollment Form
Employee Enrollment Form (Español)
Employee Change Request Form
Employee Change Request Form (Español)
Declination of Coverage Form
Request for Continuity of Care
Request for Continuity of Care (Español)
Continuity of Care Notice
Continuity of Care Notice (Español)
DELTA DENTAL
Employer Group Application
DHMO Employee Enrollment/Change Form
DHMO Employee Enrollment/Change Form (Español)
DPO Employee Enrollment/Change Form
DPO Employee Enrollment/Change Form (Español)
Declination of Coverage Form
PACIFICARE OF CALIFORNIA
Employer Group Application
Employee Enrollment Form
Employee Enrollment Form (Español)
Employee Change Request Form
Employee Change Request Form (Español)
Declination of Coverage Form
Declination of Coverage Form (Español)
Request for Continuity of Care
Request for Continuity of Care (Español)
PREMIER ACCESS
*Available for groups of 5 lives or more only.
Employer Group Application
Employee Enrollment/Change Form
Employee Enrollment/Change Form (Español)
COBRA Election Enrollment Form
SAFEGUARD VISION
Employer Group Application
Employee Enrollment Form
Employee Enrollment Form (Español)
ASSURITY LIFE INSURANCE
Employer Group Application
Employee Enrollment Form
SHARP
Employer Group Application
Employee Enrollment Form
Employee Enrollment Form (Español)
Declination of Coverage Form
Request for Continuity of Care
Frequently Asked Questions
WESTERN HEALTH ADVANTAGE
Employer Group Application
Employee Enrollment/Change Form
Declination of Coverage Form
Request for Continuity of Care
MISCELLANEOUS
Hour Bank Program Description
Hour Bank Time Line
Hours & Contribution Report
Participation & Administration Agreement
Submission Checklist
Group Information Form
New Broker Information Form
*Business Associate Agreement
*Mandatory: we cannot release any employee information to brokers without this completed form on file