Enrollment forms
Complete fillable PDFs online and then print, sign and submit them to Blue Shield. You will need Adobe Reader to complete the fillable form. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version. We recommend using our online version where it is available.
Small Businesses (1-100)
| Form | Purpose | Download/ complete online |
|---|---|---|
Master Group Application |
This application includes a checklist of all the information and forms your broker will need in order to successfully submit your application. |
2024 Application Download PDF (Spanish)1 |
| Employee Application (C12914) |
Employees should complete this application to enroll in a group medical plan, group vision plan, or group term life policy. Log in to Employer Connection to enroll a new or existing employee. |
2024 Application Download PDF (Spanish)1 |
| Disability Addendum (C11248) |
This form should accompany the new group application. |
Download PDF |
| HIPAA Release Form (A46163) |
This is an authorization for the release of personal and health information. | Download PDF (PDF, 127 KB) |
| Medicare Advantage Prescription Drug Plans Enrollment Form (MG00001) | This form is for Medicare-eligible retirees who want to enroll in Blue Shield 65 PlusSM, a group Medicare Advantage Prescription Drug plan. | Download PDF (PDF, 117 KB) |
| Medicare Prescription Drug Plan Enrollment Form (PDP00045) |
This form is for retirees who want to enroll in Blue Shield of California Medicare Rx Plan (PDP), an Enhanced Group Prescription Drug Benefit plan. | Download PDF (PDF, 118 KB) |
Large Groups (101+)
| Form | Purpose | Download/ complete online |
|---|---|---|
| Master Group Application (C14939) |
This application includes a checklist of all the information and forms your broker will need in order to successfully submit your application. |
2024 Application Download PDF (English) 2023 Application Download PDF (English) |
| Employee Application (C15390) |
Employees should complete this form to enroll in a group medical plan, group vision plan or group term life policy. Log in to Employer Connection to enroll a new or existing employee |
|
| Employee Application Medical only (C15390-H) |
Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group. |
2024 Application Download PDF (English) 2023 Application Download PDF (English) |
| Employee Application Life only (C15390-L) |
Employees should complete this form to enroll in a group term life policy. For employee enrollments to a new or existing employer group. | 2024 Application Download PDF (English) 2023 Application Download PDF (English) |
| Employee Application Medical and life (C15390-HL) |
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. | 2024 Application Download PDF (English) 2023 Application Download PDF (English) |
| Medicare Advantage Prescription Drug Plans Enrollment Form (MG00001) | This form is for Medicare-eligible retirees who want to enroll in Blue Shield 65 PlusSM, a group Medicare Advantage Prescription Drug plan. | Download PDF (PDF, 117 KB) |
| Medicare Prescription Drug Plan Enrollment Form (PDP00045) |
This form is for retirees who want to enroll in Blue Shield of California Medicare Rx Plan (PDP), an Enhanced Group Prescription Drug Benefit plan. | Download PDF (PDF, 118 KB) |
| Disability Addendum (C11248) |
This form should accompany the new group application | Download PDF (PDF, 431 KB) |
| HIPAA Release Form (A46163) |
This is an authorization for the release of personal and health information. | Download PDF (PDF, 127 KB) |
Cal-COBRA/COBRA
| Form | Purpose | Download/ complete online |
|---|---|---|
| COBRA Application (C11825-RTM) |
If you are self administering or have a third party federal COBRA administrator and you have a qualified beneficiary electing to participate in COBRA, they must complete this application. Log in to Employer Connection to enroll a new or existing employee |
Log in to complete the application online |
| Employer Notification of Qualifying Events Under Cal-COBRA (C13140) |
Complete this form when covered employees have an event that qualifies them for coverage under the California Continuation Benefits Replacement Act (Cal-COBRA, California Senate Bill 719). | Download PDF |
| Cal-COBRA Take-Over Form (C14755) |
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 PDF (PDF, 75 KB) |
| Continuing Group Coverage after FederalCOBRA Cal-COBRA Election Form (C52299) |
After exhausting 18 months of Federal COBRA benefits, a beneficiary may be eligible for an 18-month extension through Cal-COBRA. Beneficiary must contact Cal-COBRA (800-228-9476) to request the extension and ensure they meet the requirements. If approved, the beneficiary will submit this form to formally accept the extension. |
Download PDF |
| Cal-COBRA Election Form (C13141) |
Once the employer submits the ENF (C13140), an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without employer first submitting the ENF (C13140). |
Download PDF |
| Cal-COBRA Dental Election Form (C18156) |
For dental only groups: Once the employer submits the ENF (C13140), an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without employer first submitting the ENF (C13140). | Download PDF (PDF, 71 KB) |
1Complete fillable PDFs online and then print, sign and submit them to Blue Shield. You will need Adobe Reader to complete the fillable form. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version. We recommend using our online version where it is available.
W-9s and other IRS forms
Blue Shield of California plans: Download W-9 (PDF, 548 KB)
Blue Shield of California Life & Health Insurance Company plans: Download W-9 (PDF, 544 KB)
Not sure which form to use? Give us a call at (800) 325-5166.
We update these forms often, but still advise that you check the IRS website to make sure you have the most recent W-9s. You can also find the tax forms you need.
