Forms

Please fax all documents to (559) 733-3250. For questions about how to properly fill out form, please call (559) 260-5927 or (559) 827-8308. (Note: All documents below are in PDF Format. You can download Adobe Reader here.)

Employer Forms

Anthem Forms Blue Shield Forms Aetna Forms
Employee Termination Form - Notification to Anthem of Change in Employee Status, notification of termination of employee/dependents, address changes, COBRA/Cal-COBRA notifications
Employee Termination/Change Form- (Step 1 of 2) Notification to BS of Change in Employee Status

Cal-COBRA Notification Form - (Step 2 of 2) Required Notification to Begin Cal-COBRA Proceedings
Employee Termination/Change Form - This is the same form as the Employee Application. Mark the appropriate box for changes to employee status.
 
Choice Builder Humana Forms Health Edge
Employee Termination Form  Employee Termination Form CalDent/CalVision - Employee Termination/Change Form                    
SelectDent/SelectVision - Employee Termination/Change Form
     

Employee Forms

Anthem Forms                            

 Blue Shield Forms  Aetna Forms 

Employee Application - Existing Groups Only (Small Groups)

Employee Application - Large Group (51+) Employee Application

Change of Coverage Application - Use this form to switch to an alternative plan, if available.

            

Dental Plans and Rates -  Plans and Rates subject to change without notice.

                      

Vision Plans and Rates - Plans and Rates subject to change without notice.

           

Dental & Vision Brochure

Employee Application



Health Statement - REQUIRED with all new employee applications



Beneficiary Change Form - Use this form to change Life insurance beneficiary info
Employee Application
 
Choice Builder Humana Forms Health Edge           
Employee Application - New Enrolling Employees

           

Employee Renewal Change Form - For making open enrollment changes to existing coverage (add dependents, cancel coverage, etc.)
 Employee Application SelectDent/SelectVision Employee Application

                     

CalDent/CalVision Employee Application