Forms and applications

Master group application

Note: Microsoft Edge is not recommended for viewing or downloading these forms.

Effective 1/1/2025
English (PDF, 1.1 MB)
Spanish (PDF, 9.7 MB)
Chinese (PDF, 7.5 MB)
Vietnamese (PDF, 11.6 MB)
Persian (PDF, 5.7 MB)

Effective 1/1/2024
English (Fillable PDF, 1.4 MB)
Spanish (Fillable PDF, 1.9 MB)
Chinese (Fillable PDF, 3 MB)
Vietnamese (Fillable PDF, 2.7 MB)
Persian (Fillable PDF, 3.5 MB)

Effective 1/1/2023
English (Fillable PDF, 1.3 MB)
Spanish (Fillable PDF, 697 KB)
Chinese (Fillable PDF, 863 KB)
Vietnamese (Fillable PDF, 815 KB)
Persian (Fillable PDF, 815 KB)

Subscriber change request
Employees can change personal information, change plans during open enrollment, enroll new dependents or cancel dependents (include Refusal or Cancellation of Personal Coverage form).

Effective 1/1/2025
English (PDF, 703 KB)
Spanish (PDF, 952 KB)
Chinese (PDF, 949 KB)
Vietnamese (PDF, 1.1 MB)
Persian (PDF, 957 KB)

Effective 1/1/2024
English (Fillable PDF, 706 KB)
Spanish (Fillable PDF, 952 KB)
Chinese (Fillable PDF, 949 KB)
Vietnamese (Fillable PDF, 1.1 MB)
Persian (Fillable PDF, 957 KB)

Effective 1/1/2023
English (Fillable PDF, 545 KB)
Spanish (Fillable PDF, 551 KB)
Chinese (Fillable PDF, 733 KB)
Vietnamese (Fillable PDF, 561 KB)
Persian (Fillable PDF, 691 KB)

Employee change/cancellation transmittal
Submit a monthly summary of employee cancellations and/or changes.

Employer questionnaire

Evidence of Insurability

Refusal of Personal Coverage form
Employees should complete this form if they, their spouse/domestic partner of dependents are refusing their employer's medical or dental plan coverage.

Declaration of Disability of Over Age Dependent Children
For enrolled dependent children who normally lose their eligibility because of age, but who are disabled by reason of a physically or mentally disabling injury.

Subscriber disability
File for an extension of benefits. Administrators must also complete the Notice of Total and Permanent Disability Form.

Disability addendum

Authorization for the Release of Health Information

Additional Contact Designation Form: Notice of Lapse or Termination of Life Insurance Policy for Non-Payment of Premium

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).

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, 57 KB)

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 fill out the form and submit to the Cal-COBRA team within 30 days of transition.

Download (Fillable PDF, 100 KB)

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.