ChoiceBuilder

ChoiceBuilder gives employers with 2-199 employees access to some of the nations premier dental, vision, chiropractic and life carriers – all in one program. Whether you’re already offering optional benefits, or looking to add them for the first time, with ChoiceBuilder you can pick and choose the benefits you like best and build a program that makes sense for your business, your budget and your employees.

 Provider Finder 

Form Name Effective Date Download Form
New Group Submission
Case Submission Checklist 3.21
03/01/2021 Download
Employer Application 3.21 - 12.21 Effective Dates
03/01/2021 Download
Employer Application 1.22 - 3.22 Effective Dates
01/01/2022 Download
Initial Payment Form (One-Time ACH) 1.20
01/01/2021 Download
Initial Payment Form (One-Time ACH) 1.22
01/01/2022 Download
Late Submission Acknowledgment
01/01/2020 Download
Owner/ Partner Statement
01/01/2020 Download
Common Ownership Statement
01/01/2020 Download
Confirmation of Eligibility
01/01/2020 Download
Prior Carrier Cancel Template
01/01/2020 Download
In Force Group Forms
Employer Change Request Form 3.21 to 12.21 Effective Dates
03/01/2021 Download
Employer Change Request Form 1.22 to 3.22 Effective Dates
01/01/2022 Download
Employee Termination Notification Form
01/01/2020 Download
Annual COBRA/CalCOBRA Status Notification
01/01/2020 Download
COBRA Participant Cancellation Notice
01/01/2020 Download
Administration
Employer Administrative Guide 3.21
03/01/2021 Download
Form Name Effective Date Download Form
Enrollment and Change Forms
Employee Enrollment Form 3.21 - 12.21 Effective Dates
03/01/2021 Download
Employee Enrollment Form 1.22 - 3.22 Effective Dates
01/01/2022 Download
Employee Change Request Form 1.21
01/01/2021 Download
Employee Change Request Form 1.22
01/01/2022 Download
Affidavit of Domestic Partnership
01/01/2020 Download
Disabled Dependent Certifcation
01/01/2020 Download
Eyemed Vision Claim Form
01/01/2020 Download
VSP Vision Request for Reimbursement Form
01/01/2020 Download
COBRA and Cal-COBRA Forms
COBRA Enrollment Form 1.21
01/01/2021 Download
COBRA Enrollment Form 1.22
01/01/2022 Download
COBRA Dependent Qualifying Event Notification
01/01/2020 Download
Form Name Effective Date Download Form
2021 Plan Summaries
Dental
Delta Care DHMO - Employer Sponsored & Voluntary
01/01/2021 Summary
Ameritas DPPO - Employer Sponsored & Voluntary
01/01/2021 Summary
Anthem DPPO - Employer Sponsored & Voluntary
01/01/2021 Summary
Delta Dental DPPO - Employer Sponsored & Voluntary
01/01/2021 Summary
MetLife DPPO - Employer Sponsored & Voluntary
01/01/2021 Summary
Vision
Vision (EyeMed) - Employer Sponsored & Voluntary
01/01/2021 Summary
Vision (VSP) - Employer Sponsored & Voluntary
01/01/2021 Summary
Chiropractic & Acupuncture
Chiropractic & Acupuncture - Employer Sponsored & Voluntary
01/01/2021 Summary
Life
Life Benefit Grid - Employer Sponsored
01/01/2021 Summary
2020 Plan Summaries
Dental - Employer Sponsored
Delta Care DHMO - Employer Sponsored
07/01/2020 Summary
Ameritas DPPO - Employer Sponsored
07/01/2020 Summary
Anthem DPPO - Employer Sponsored
07/01/2020 Summary
Delta Dental DPPO - Employer Sponsored
07/01/2020 Summary
MetLIfe DPPO - Employer Sponsored
07/01/2020 Summary
Dental - Voluntary
DeltaCare DHMO - Voluntary
07/01/2020 Summary
Ameritas DPPO - Voluntary
07/01/2020 Summary
Anthem DPPO - Voluntary
07/01/2020 Summary
Delta Dental DPPO - Voluntary
07/01/2020 Summary
MetLife DPPO - Voluntary
07/01/2020 Summary
Vision
Vision (EyeMed & VSP) - Employer Sponsored
07/01/2020 Summary
Vision (EyeMed & VSP) - Voluntary
07/01/2020 Summary
Chiropractic & Acupuncture
Chiropractic & Acupuncture - Employer Sponsored & Voluntary
07/01/2020 Summary
Life
Life Benefit Grid - Employer Sponsored
07/01/2020 Summary
Form Name Effective Date Download Form
General Information
ChoiceBuilder Employer Brochure 3.21
01/01/2020 Download
ChoiceBuilder Program Highlights Brochure
01/01/2020 Download
ChoiceBuilder Advantage Brochure
01/01/2020 Download
ChoiceBuilder At a Glance Flyer
01/01/2021 Download
ChoiceBuilder Benefit Summary Sales 3.21
03/01/2021 Download
ChoiceBuilder Benefit Summary Sales 1.22
01/01/2022 Download
American Rescue Plan Act Employer Notification
06/01/2021 Download
Broker Licensing - Ameritas
01/01/2020 Download
CalPerks Flyer
01/01/2020 Download
Employee Enrollment Guide 3.21
03/01/2021 Download
Fast Facts Brochure
03/01/2021 Download
Online Provider Search Instructions
01/01/2020 Download
Premium Only Plan Flyer
01/01/2020 Download
Program Highlights
01/01/2021 Download
Summary of Changes 3.21 to 12.21 Effective Dates
03/01/2021 Download
Summary of Changes 1.22 to 3.22 Effective Dates
01/01/2022 Download
Value Added Online HR Support Flyer
01/01/2020 Download
Underwriting Guidelines 3.21
03/01/2021 Download
Form Name Effective Date Download Form
ChoiceBuilder Rate Summary [effective 8/1/2021 to 12/1/2021]
08/01/2021 Download
ChoiceBuilder Rate Summary [effective 1/1/2021 to 3/1/2022]
01/01/2022 Download