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"

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.

© 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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