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- New Group/New Employee Only

Employee Application - Existing Groups Only

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