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Forms

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2-50 Small Group Employer Application
2-50 Existing Small Group Employee Addition Application
Small Group Change of Coverage Application
Dental Coverage Employee Application
Small Group Benefit Modification Inquiry
Prescription Drug Claim Form
Small Group Remittance Report
Use this form to report termination of employees and/or dependents, address change for covered employees, or COBRA/Cal COBRA notifications.
Standard Enrollment/Translator's Statement
When completing the Small Group Employee Application and a translator assists you, the translator must complete this form and attach it to the application.
Patient Claim Form
When an employee receives services from a health care provider, the health care provider submits the claim directly to Blue Cross. However, in certain circumstances the employee may be required to submit a claim form. See page 1 of this form for instructions.
Affidavit of Domestic Partnership
If an employer offers the domestic partner eligibility option to their employees, and an employee wishes to add their domestic partner to their plan, the employee must complete and submit this form along with an Employee Application requesting enrollment.
Cal-COBRA/COBRA and Medicare Survey
In order to ensure compliance with state and federal laws, you are required to update Blue Cross annually with your company's Cal-COBRA or COBRA and Medicare eligibility for the upcoming year.
Small Group Required Information Checklist
Accelerated Death Benefit Attending Physician's Statement
Claim for Personal Accelerated Death Benefit
Beneficiary Claim Form & Group Policyholder's Statement
Absolute Assignment
Change of Beneficiary and/or Name
Statement of Attending Physician (Dismemberment)

Standard Health Plans Applications

Aetna

Anthem BC Life and Health Insurance Company Tonik

Anthem Blue Cross of California

Blue Shield of California

Health Net of California

Health Net of California Farm Bureau

Kaiser Permanente

Temporary Health Plans Applications

Anthem BC Life and Health Insurance Company

Assurant

Health Net of California

Health Plans

Anthem Blue Cross Blue Shield
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PacifiCare
Health insurance pacificare \| Annunity pacificare insurance \| Pacificare life insurance

Health Insurance
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Dental Plans
Dental plans \| Dental coverage

Long Term Insurance
Long term insurance \| Long term Health insurance \| California long term insurance \| Long term dental insurance \| Long term group insurance \| Long Term Pacificare \| Long term insurance quote \| Long term Health net \| Long term blue shield \| Long term life insurance \| Long Term Medical Quote

Kaiser
Health insurance kaiser \| kaiser long term \| kaiser life insurance \| Annunity kaiser health insurance \| Individual health insurance kaiser

PPO Plans
ppo 500 \| ppo 1000 \| ppo 2000 \| ppo 250 \| ppo 40 comprehensive \| ppo 250 \| ppo generic \| ppo saver \| ppo share 5000

Workers Pension
Kaiser group plans workers pension \| Kaiser workers pension \| Health insurance workers pension \| ppo plans workers pension \| Health net workers pension \| Blue shield workers pension \| Anthem Blue cross workers pension \| Pacificare workers pension

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