Online Documents

Insurance Enrollment Documents

• Small Group Employer Application (2-50 enrolled employees)
• Small Group Employee Application (2-10 enrolled employees)
• Small Group Employee Application (11-50 enrolled employees)
• Sole Proprietor, Partner, or Corporate Officer Statement
• Affidavit of Domestic Partnership
• Addendum to Small Group Employer Application
• Group Administrator Manual
• Small Group Change of Coverage Application
• Patient Claim Form
• Small Group Employee Information Change Form
• Absolute Assignment
• Statement of Attending Physician
• Beneficiary Claim Form
• Small Group Benefit Modification Inquiry
• Small Group Checklist
• Change of Beneficiary
• Cobra Eligibility Notification
• Small Group Remittance Schedule

• Small Group (2-50) Master Application
• Small Group Employee Application (2-14 enrolled employees)
• Small Group Employee Application (15-50 enrolled employees)
• Group (2-299) Master Application
• Group Employee Application (2-299 enrolled employees)
• Refusal of Personal Coverage
• Affidavit of Domestic Partnership
• Full Time Student Certification
• Subscriber Change Request
• Cobra Application
• Cobra Take-Over Form
• Direct Reimbursement Claim
• Subscriber's Statement of Claim
• Sole Proprietor or Partner Statement
• Request for Continuity of Coverage

• Claim Form - Dental
• Dental Enrollment Owner / Partner Statement
• Employee Dental Application
• Stand-Alone Group Dental Application
• Submission Checklist - Stand Alone Dental

• Small Group Employer Application
• Small Group Employee Application
• Cobra Enrollment Application
• Declination of Coverage
• Proprietor/Partner Form
• Affidavit for Enrollment of Domestic Partners
• Account Change Form
• Student Certification
• Transfer Request

• Small Group Employer Application
• Small Group Employee Application
• Cobra Application
• Cobra Statement
• Owner/Partner Statement
• Full Time Student Verification
• Affidavit of Domestic Partnership
• Domestic Partner Application
• Small Group Disclosure
• Agent Agreement
• Broker Disclosure
• Broker Licensing Form
• Termination of Group Insurance
• Change Request Form
• Common Ownership Statement
• Disabled Dependent Certification
• Small Group Employee New Hire Application
• Termination of Employment/Reduction in Hours
• Late Submission Acknowledgement
• Proposal Request
• SB578 Statement of Qualification

• Delta Dental Group Application
• Submission Checklist - Delta Dental
• Submission Checklist - Delta Premier
• Employee Enrollment / Change Form
• Declining Dental Coverage Form
• Delta Care / PMI HIPAA BA Agreement

• Small Group Employee Application - HMO
• Small Group Employee Application - PPO
• Waiver of Group Medical Coverage
• Declaration of Domestic Partnership
• Small Group Employee Disclosure
• Enrollment/Change Request
• Employer Certification Form
• Employer Verification Form
• Health Statement
• Group Medical Questionnaire

• Small Group Employer Application (Effective April/2005)
• Employee Change Request Form
• Small Group Employee Application (Effective April/2005)
• Small Group Employer Acceptance/Change Application (Effective April/2005)
• Claim Form for Self Directed Health Plans
• Cobra Election Form
• Cal Cobra Election Form
• Cal Cobra Qualifying Event Form
• Affidavit of Domestic Partnership Form
• Employee Declination of Coverage Form
• Employer Group Reporting Form
• Individual Health Statement Application
• HIPAA Authorization Form
• Proprietor Statement Form
• Rx Reimbursement Form
• Student Status Form

• Small Group Employer Application
• Small Group Employee Application
• Cetification to Waive/Decline Coverage
• Declaration of Domestic Partnership Form
• Cobra Enrollment Application
• Annual Requalification and Open Enrollment Form
• Dependent Enrollment Application
• Employee/Member Open Enrollment Change Form
• Electronic Funds Transfer Form
• Association Member Application
• Open Enrollment Change Form
• Employer Census Form
• Termination Form

• Small Group Employer Application
• Small Group Employee Application
• Small Group Employee Application - Domestic Partner
• Domestic Partner Affidavit
• Small Business Group Submission Checklist
• Underwriting Guidelines
• Health Questionnaire

• Small Group Employer Application
• Small Group Employee Application
• Small Group Requirements for Proof of Eligibility
• Declaration of Domestic Partnership
• Declination of Coverage
• New Group Submission/Employer's Checklist

• Small Group Employer Application
• Small Group Employee Application (2-19 enrolled employees)
• Small Group Employee Application (20+ enrolled employees)
• New Group Submission Checklist
• Risk Evaluation Form
• Employee Census

• Small Group Employer Application
• Small Group Employee Enrollment/Change Form
• Small Group Employee Health Statement (2-13 Eligible Employees)
• Waiver of Coverage
• Proprietor or Partnership Form
• Electronic Funds Transfer Agreement
• Domestic Partners - Eligibility and Enrollment
• Transition of Care Form