| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
Case Submission Checklist 7.22 |
10/01/2023 | Download |
|
Employer Application (Effective Dates after 7.23) |
10/01/2023 | Download |
|
Initial Payment Form (One-Time ACH) 1.22 |
12/01/2022 | Download |
|
Late Submission Acknowledgment |
01/01/2020 | Download |
|
Owner/ Partner Statement |
12/01/2022 | Download |
|
Common Ownership Statement |
12/01/2022 | Download |
|
Confirmation of Eligibility |
04/01/2023 | Download |
|
Prior Carrier Cancel Template |
01/01/2020 | Download |
|
In Force Group Forms |
||
|
Employer Change Request Form 1.23 Effective Dates |
01/01/2023 | Download |
|
Employer Change Request Form 12.22 Effective Dates |
12/01/2022 | Download |
|
Employer Change Request Form 7.22 Effective Dates |
07/01/2022 | Download |
|
Employee Termination Notification Form |
12/01/2022 | Download |
|
Annual COBRA/CalCOBRA Status Notification |
01/01/2023 | Download |
|
COBRA Participant Cancellation Notice 1.24 |
01/01/2024 | Download |
|
COBRA Participant Cancellation Notice 1.23 |
12/01/2022 | Download |
|
Administration |
||
|
Employer Administrative Guide 4.23 |
04/01/2023 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Employee Enrollment Form (Effective Dates after 4/1/24) |
04/01/2024 | Download |
|
Employee Enrollment Form (Effective Dates after 1/1/24) |
01/01/2024 | Download |
|
Employee Change Request Form (Effective Dates after 4/1/24) |
04/01/2024 | Download |
|
Employee Change Request Form (Effective Dates after 1/1/24) |
01/01/2024 | Download |
|
Affidavit of Domestic Partnership |
12/01/2022 | Download |
|
Disabled Dependent Certifcation |
12/01/2022 | Download |
|
Eyemed Vision Claim Form |
01/01/2020 | Download |
|
VSP Vision Request for Reimbursement Form |
12/01/2022 | Download |
|
COBRA and Cal-COBRA Forms |
||
|
COBRA Enrollment Form 1.22 |
12/01/2022 | Download |
|
COBRA Dependent Qualifying Event Notification |
01/01/2020 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
2024 Plan Summaries |
|||
|
Dental |
|||
|
Delta Care DHMO - Employer Sponsored & Voluntary |
01/01/2024 | Summary | |
|
Ameritas DPPO - Employer Sponsored & Voluntary |
01/01/2024 | Summary | |
|
Anthem DPPO - Employer Sponsored & Voluntary |
01/01/2024 | Summary | |
|
Delta Dental DPPO - Employer Sponsored & Voluntary |
01/01/2024 | Summary | |
|
MetLife DPPO - Employer Sponsored & Voluntary |
01/01/2024 | Summary | |
|
Vision |
|||
|
Vision (EyeMed) - Employer Sponsored & Voluntary |
01/01/2024 | Summary | |
|
Vision (VSP) - Employer Sponsored & Voluntary |
01/01/2024 | Summary | |
|
Chiropractic & Acupuncture |
|||
|
Chiropractic & Acupuncture - Employer Sponsored & Voluntary |
01/01/2024 | Summary | |
|
Life |
|||
|
Life Benefit Grid - Employer Sponsored |
01/01/2024 | Summary | |
|
2023 Plan Summaries |
|||
|
Dental |
|||
|
Delta Care DHMO - Employer Sponsored & Voluntary |
01/01/2023 | Summary | |
|
Ameritas DPPO - Employer Sponsored & Voluntary |
01/01/2023 | Summary | |
|
Anthem DPPO - Employer Sponsored & Voluntary |
01/01/2023 | Summary | |
|
Delta Dental DPPO - Employer Sponsored & Voluntary |
01/01/2023 | Summary | |
|
MetLife DPPO - Employer Sponsored & Voluntary |
01/01/2023 | Summary | |
|
Vision |
|||
|
Vision (EyeMed) - Employer Sponsored & Voluntary |
01/01/2023 | Summary | |
|
Vision (VSP) - Employer Sponsored & Voluntary |
01/01/2023 | Summary | |
|
Chiropractic & Acupuncture |
|||
|
Chiropractic & Acupuncture - Employer Sponsored & Voluntary |
01/01/2023 | Summary | |
|
Life |
|||
|
Life Benefit Grid - Employer Sponsored |
01/01/2023 | Summary |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
ChoiceBuilder Sales Brochure 1.24 |
01/01/2024 | Download |
|
ChoiceBuilder Fast Facts Brochure 1.24 |
01/01/2024 | Download |
|
ChoiceBuilder Program Highlights Flyer 1.24 |
01/01/2024 | Download |
|
ChoiceBuilder Employer Brochure 7.23 |
10/01/2023 | Download |
|
ChoiceBuilder Program Guidelines 7.23 |
07/01/2023 | Download |
|
ChoiceBuilder Benefit Summary 1.24 |
01/01/2024 | Download |
|
Broker Licensing - Ameritas |
01/01/2022 | Download |
|
CalPerks Flyer |
10/01/2023 | Download |
|
Employee Enrollment Guide 1.24 |
01/01/2024 | Download |
|
Online Provider Search Instructions |
01/01/2025 | Download |
|
Premium Only Plan Flyer 7.22 |
09/01/2022 | Download |
|
Summary of Changes 4.24 to 6.24 Effective Dates |
04/01/2024 | Download |
|
Summary of Changes 1.24 to 3.24 Effective Dates |
01/01/2024 | Download |
|
Value Added Online HR Support Flyer |
01/01/2022 | Download |
|
Underwriting Guidelines 4.23 |
10/01/2023 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
ChoiceBuilder Rate Summary [effective 1/1/2024] |
01/01/2024 | Download |
