Small Business library
Documents library
Current forms and applications, July 1, 2024 to September 30, 2024
Employee application English (PDF, 1.5 MB), Spanish (PDF, 1.6 MB)
Enrollment spreadsheet with Master Group agreement Download (1.2 MB)
Group Change Request English (PDF, 724 KB), Spanish (PDF, 637 KB)
Master Group application English (PDF, 640 KB), Spanish (PDF, 640 KB)
Subscriber Change Request English (PDF, 1.3 MB), Spanish (PDF, 1.4 MB)
Refusal of Coverage English (PDF, 764 KB), Spanish (PDF, 881 KB)
Other useful documents from across the small business Broker Connection pages, organized from A to Z
Accelerated Death Benefit claim
Additional Contact Designation Notice of Lapse or Term of Policy for Non-Payment
American Specialty Health (ASH) – Subscriber claim
Authorization to Disclose Health Information
Away From Home Care (HMO Only)
BlueCard Worldwide International claim
Book of Business transfer request
COBRA and Cal-COBRA Continuation of Coverage
Cal-COBRA Employer Notification of Qualifying Events
Changes to (2024) HMO Mirror | HMO Off-Exchange | PPO Mirror | PPO Off-Exchange | PPO Savings Off-Exchange | Specialty
Changes to (2023) HMO Mirror | HMO Off-Exchange | PPO Mirror | PPO Off-Exchange | PPO Savings Off-Exchange
Changes to medical plan names 2024 | 2023
Conversion to Individual Coverage of Group Life
Declaration of Disability of Over Age-Dependent Children
Employee Cancellation notification
Find a doctor English | Spanish
Find dental and vision providers of your choice
HIPAA Authorization for Release of Personal and Health Information form (fillable)
Identity Theft Protection Services English | Spanish
Key contacts and estimated times
Managing your dental plan online
Managing your vision plan online
Member Guide to orthodontic coverage English | Spanish
New Group submission checklist
Notice informing individual about nondiscrimination and accessibility requirements
Notification of CMS reporting requirements
NurseHelp 24/7 English | Spanish
Online and mobile tools English | Spanish
Pediatric dental and vision FAQs
Pharmacy reimbursement form English | Spanish
Premium Only Plan (POP) by HealthEquity
Preventive health guidelines English | Spanish
Print or order ID card English | Spanish
Sales guide - Medical Q3 2024 | Q2 2024 | Q1 2024 | Q4 2023
Sales guide - Specialty Q3 2024 | Q2 2024 | Q1 2024 | Q4 2023
Small Business administrator's guide 2024 | 2023
Small Business service support
Small Group initial payment form
Small Group Broker of record change
Sole proprietor, Partner of Corporate Office statement
Specialty drug list for Standard Drug Formulary
Start-up / Spin-off Eligibility attestation
Subscriber Statement of claim - Life
Teladoc 2024 English | Spanish
Teladoc 2023 English | Spanish
Tivity Health Fitness Your Way English | Spanish
Total Health and Wellness English | Spanish
Underwriting guidelines 2024 | 2023
Vaccine list English | Spanish
Value-Based Benefits Plan brochure
Vision Plan info card for CA members English | Spanish
Wellness discounts
