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Agents:  
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Danny Goldman


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Employer Small Group Applications

Please Press Right mouse click of an application and view it in a new window

Employee Application (right click - click open in a new window)
Employer Application (right click - click open in a new window)

2-50 Small Group Employee Application
2-50 Small Group Employer Application
Sole Proprietor, Partner, or Corporate Officer Statement

Addendum to Small Group Employer Application
Absolute Assignment
Accelerated Death Benefit Statement
Affidavit of Domestic Partnership
Beneficiary Claim Form

Claim for Personal Accelerated Death Benefit
COBRA Cal COBRA
Patient Claim Form
Small Group Change of Coverage Application
Small Group Dental Employee Application
Small Group Remittance Schedule
Small Group Required Information Checklist
Statement of Attending Physician
Translators Statement

Cal COBRA Takeover Form
Change Request Form (Spanish)
COBRA Application
Direct Reimbursement Claim
Employee Application (2-24)
Employee Application (25+)
Employee Application (300+)

Full Time Student Certification
International Claim Form
Refusal of Personal Coverage
Statement of Domestic Partnership
Subscribers Statement of Claim
Master Group Application

Employer Application
Employee Application
Employee Application (Spanish)
Change Request
Change Request (Spanish)
Employee Health Questionnaire

Salud Application
Domestic Partner Affidavit
Domestic Partner Affidavit (Spanish)
Disabled Dependent Certification
Student Verification

Blue Shield RX Claim Form
Blue Shield Medical Claim Form
Cigna Medical Claim Form
Health Net Medical Claim Form

Account Transfer Form
Customer Agreement Form
Disclosure Authorization Form A
Disclosure Authorization Form B
Disclosure Authorization Form C
Group Dental Claim Form

Health Insurance Claim Form
International Medical and Dental Claim Form

Change Req uest Form
Change Request Form - HMO (Spanish)
Change Request Form - POS (Spanish)
COBRA Election Form
Employee Enrollment and Declination of Coverage Form

POS Medical Claim Form
Prescription Mail Order
Prescription Mail Order - HMO (Spanish)
Prescription Mail Order - POS (Spanish)

Small Group Employee Enrollment Form - HMO (Spanish)
Small Group Employee Enrollment Form - POS (Spanish)
Small Group Employer Application and Questionnaire
Small Business Individual Health Statement Application
Group Acceptance/Change Form (GAF)

Affidavit of Domestic Partnership
Health Questionnaire
Health Questionnaire (Spanish)

Small Business Employee Enrollment Form

Small Business Employee Enrollment Form (Spanish)
Small Business Plans Group Service Agreement
Underwriting Guidelines

Domestic Partner Affidavit
Employee Enrollment Application
Employee Enrollment Application w/ Health Questionnaire (6-15 EE's)
New Group Application

Domestic Partner Affidavit
Employee Enrollment Application (Spanish)
Employee Enrollment Application w/ Health Questionnaire (6-15 EE's) (Spanish)

Annual Requalification and Open Enrollment Form
Association Enrollment
Association Open Enrollment Change Form
Cal COBRA and COBRA Enrollment
Certification to Waive and Decline Coverage
Dependent Enrollment in Spanish
Dependent Enrollment
Domestic Partnership Declaration Form
Electronic Funds Transfer Form
Employee Change Form in Spanish
Employee Enrollment in Spanish
Employee Enrollment
Employee Open Enrollment Change Form
Employer Census Form
Employer Enrollment
Member Termination Form
Certification of Corporate Wage Earner of Self Employed Income

Change Request Form
Change Request Form - HMO (Spanish)
Change Request Form - POS (Spanish)
COBRA Election Form

Employee Enrollment and Declination of Coverage Form
POS Medical Claim Form
Prescription Mail Order
Prescription Mail Order - HMO (Spanish)
Prescription Mail Order - POS (Spanish)

Small Group Employee Enrollment Form - HMO (Spanish)
Small Group Employee Enrollment Form - POS (Spanish)
Small Group Employer Application and Questionnaire
Small Business Individual Health Statement Application
Group Acceptance/Change Form (GAF)

Broker Alert Flyer
Declaration of Domestic Partnership
Declination of Coverage Form
Employer's Group Submission Checklist
Master Application
Enrollment Application
Small Group Statement

Application and Enrollment Form
Application and Enrollment Form (20+)
Employee Census
Universal Care Group Application
Universal Care Risk Evaluation Form

Domestic Partner Form
Electronic Funds Transfer sAgreement
Employer Group Application
Enrollment Change Form
Health Statement
Proprietor and Partnership Form
Transition of Care Form
Waiver of Coverage

 

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