/Combined Medical and Specialty Employer Application

Medical Only Employer Application

 

Forms

Cobra, Cal Cobra and Medicare Survey

Census Tool Instructions

Simple Census 1.99.22

Plan Change Request Form

Eligibility statement

Conditions of Enrollment/Start-Ups/PEO

Information Change Form

Electronic Debit Payment Form

Reinstatement Electronic Debit Payment Form

Authorization Request by Phone for Electronic Check/ACH

Life Conversion Form

Religious Employer Self-Certification Form

Employer Access Guide

Group Administration Guide

Documents/Forms for employees
 

Employee Applications

Combined Medical and Specialty Employee Application

Combined Medical and Specialty Employee Waiver Form

Employee Application - Spanish

Employee Application - Chinese

Employee Application - Korean

Employee Application - Vietnamese

Employee Application - Tagalog

Employee Waiver Form - Spanish

Employee Waiver Form - Chinese

Employee Waiver Form - Korean

Employee Waiver Form - Vietnamese

Employee Waiver Form - Tagalog

 

Employee forms

Custodial Verification Form

Handicapped Dependent Certification Form

Member Authorization Form

Member Authorization Form (Spanish)

Member Social Security Number Exception Request Form

Statement of Accountability/Translator’s Statement

Continuity of Care/Transition of Care Form

Continuity of Care/Transition of Care Form (Spanish)

Parent Child relationship certification

Absolute Assignment Form

Evidence of Insurability

Evidence of Insurability (Spanish)

Beneficiary DesignationForm

Medical Claim Form

Medical Claim Form (Spanish)

Medical Claim Form (Chinese)

Medical Claim Form (Korean)

Medical Claim Form (Vietnamese)

Medical Claim Form (Tagalog)

Dental Claim Form

Prescription Drug Claim Form

Prescription Drug Claim Form Spanish

Vision Claim Form

Accidental Dismemberment or Loss of Sight Claim Form

Accidental Dismemberment or Loss of Sight Claim Form (Spanish)

Group Life Beneficiary Claim Form

Group Life Beneficiary Claim Form (Spanish)

Individual Life Claim Form

Life Waiver of Premium Claim Form

Living Benefit Claim Form

Living Benefit Claim Form (Spanish)

Long Term Disability (LTD) Claim Form

Long Term Disability (LTD) Claim form (Spanish)

Short Term Disability (STD) Claim Form

Short Term Disability (STD) Claim Form (Spanish)

 

Dental forms

Dental Prime and Dental Complete Additional Cleaning Form

Dental Blue Additional Cleaning form

International Emergency Dental Program flier