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
01/01/2019 Download
Employer Application 1.20
01/01/2020 Download
Employer Application 1.19
01/01/2019 Download
Initial Payment Form (One-Time ACH)
01/01/2019 Download
Late Submission Acknowledgment
01/01/2019 Download
Owner/ Partner Statement
01/01/2019 Download
Common Ownership Statement
01/01/2019 Download
Confirmation of Eligibility
01/01/2019 Download
Prior Carrier Cancel Template
01/01/2019 Download
In Force Group Forms
Employer Change Request Form 1.20
01/01/2020 Download
Employer Change Request Form 1.19
01/01/2019 Download
Employee Termination Notification Form
01/01/2019 Download
Annual COBRA/CalCOBRA Status Notification
01/01/2019 Download
COBRA Participant Cancellation Notice
01/01/2019 Download
Administration
Administrative Guidelines For Employers
01/01/2019 Download
Form Name Effective Date Download Form
Enrollment and Change Forms
Employee Enrollment Form 1.20
01/01/2020 Download
Employee Enrollment Form 5.19
05/01/2019 Download
Affidavit of Domestic Partnership
01/01/2019 Download
Disabled Dependent Certifcation
01/01/2019 Download
Employee Change Request Form 1.20
01/01/2020 Download
Employee Change Request Form 5.19
05/01/2019 Download
COBRA and Cal-COBRA Forms
COBRA Enrollment Form
01/01/2019 Download
COBRA Dependent Qualifying Event Notification
01/01/2019 Download
Form Name Effective Date Download Form
Dental - Employer Sponsored
Delta Care DHMO - Employer Sponsored
01/01/2019 Summary
Delta Care DHMO - Employer Sponsored [effective 5.19]
05/01/2019 Summary
Ameritas DPPO - Employer Sponsored
01/01/2019 Summary
Anthem DPPO - Employer Sponsored
01/01/2019 Summary
Delta Dental DPPO - Employer Sponsored
01/01/2019 Summary
MetLIfe DPPO - Employer Sponsored
01/01/2019 Summary
Dental - Voluntary
DeltaCare DHMO - Voluntary
01/01/2019 Summary
DeltaCare DHMO - Voluntary [Effective 5.19]
05/01/2019 Summary
Ameritas DPPO - Voluntary
01/01/2019 Summary
Anthem DPPO - Voluntary
01/01/2019 Summary
Delta Dental DPPO - Voluntary
01/01/2019 Summary
MetLife DPPO - Voluntary
01/01/2019 Summary
Vision
Vision (EyeMed & VSP) - Employer Sponsored
01/01/2019 Summary
Vision (EyeMed & VSP) - Voluntary
01/01/2019 Summary
Chiropractic & Acupuncture
Chiropractic & Acupuncture - Employer Sponsored & Voluntary
01/01/2019 Summary
Life
Life Benefit Grid - Employer Sponsored
01/01/2019 Summary
Form Name Effective Date Download Form
Choice Builder Employer Brochure
01/01/2019 Download
Choice Builder Program Highlights Brochure
04/01/2019 Download
Choice Builder Advantage Brochure
07/01/2019 Download
Choice Builder Anthem DPPO Annual Max Carry Over Brochure
01/01/2019 Download
CalPerks Flyer
04/01/2019 Download
Employee Enrollment Guide 1.19
01/01/2019 Download
Employee Enrollment Guide 5.19
05/01/2019 Download
Provider Search Instructions
01/01/2019 Download
Summary of Changes 1.19
01/01/2019 Download
Summary of Changes 5.19
05/01/2019 Download
Summary of Changes 7.19
07/01/2019 Download
Value Added HR Support Flyer
01/01/2019 Download
Underwriting Guidelines
01/01/2019 Download
Form Name Effective Date Download Form
Choice Builder Contact Sheet
Download