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Covered California for Small Business Change Request Form for Employers | Version CCSB V3.102319 2020
Employer name
CCSB
Group #
NEED HELP WITH THIS FORM? Contact your Covered California Certified Insurance Agent with questions, visit CoveredCA.com or call us at
(855) 777-6782. Para obtener una copia de este formulario en Español, llame (855) 777-6782.
To participate in Covered California for Small Business, you must attest to the following:
A.) I understand that the information I provided on this form will only be used to determine eligibility for and to facilitate enrollment in health coverage and
will be kept private as required by federal and state law.
B.) My waiting period is in compliance with 42 U.S.C. § 300gg-7, Section 10198.7(c) of the California Insurance Code, as amended by Statutes 2013-2014, 1st
Ex. Sess., ch. 1, § 7 and Section 1357.51(c) of the California Health and Safety Code, as amended by Statutes 2013-2014, 1st Ex. Sess., ch. 2, § 2, and all of my
qualified employees have complied with the waiting period;
C.) If my employee roster is included, I have consent from everyone I have listed on this application to include their personally identifiable information,
including but not limited to dates of birth, Social Security or tax identification numbers, addresses, and phone numbers.
D.) I know that under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity,
disability, religion, marital status or veteran status.
E.) I know that CCSB will not consider my group coverage approved until CCSB has received 85 percent of the first month's premium payment.
F.) I know that I must continue to make the required premium payments to continue to be an eligible employer in CCSB.
G.) I know that I must inform all eligible employees of the availability of coverage and that those not electing coverage must wait one year or experience a
qualifying event to obtain coverage through my group plan if they later decide they would like to have coverage.
H.) I understand that once coverage is approved by CCSB, changes to the coverage cannot be implemented after my effective date until my next annual
election of coverage period, except to the extent the qualified employer exercises the right to change coverage with the same issuer within the first 30
days of the effective date of coverage pursuant to Health and Safety Code 1357.504 (c) and the Insurance Code Section 10753.06.5 (c).
I.) I understand that health insurance coverage through the CCSB is subject to the applicable terms and conditions of the QHP issuer contract or policy and
applicable state law, which will determine the procedures, exclusions and limitations relating to the coverage and will govern in the event of any conflict
with CCSB or QHP issuer benefits comparison, summary or other description of coverage.
J.) I understand that once membership information is transmitted to the selected health plan issuers, group coverage effective dates cannot be changed
nor can coverage be terminated until after the first month of coverage.
K.) I understand that the attestations in this section are subject to audit by CCSB at any time.
L.) I understand that the attestations in this section must be maintained in order for my group to continue coverage through CCSB.
M.) I certify that the total number of Full-Time Equivalent (FTE) employees that I have provided in box 7, page 2 of this application is true and correct to the
best of my knowledge.
☐ I have read and attest to the foregoing requirements for participation in CCSB.
Binding Arbitration Agreement:
I understand that, if I select a Health Plan that uses mandatory binding arbitration to resolve disputes, I am agreeing to arbitrate claims that relate to my or a
dependent's membership in the Health Plan (except for Small Claims Court cases and claims that cannot be subject to binding arbitration under governing
law). I understand that any dispute between myself, my heirs, relatives, or other associated parties on the one hand and the Health Plan, any contracted
health care providers, administrators, or other associated parties on the other hand for alleged violation of any duty arising out of or related to
membership in the Health Plan, including , for premises liability, relating to the coverage for, or delivery of, services or items, or, if I select a Kaiser
Permanente Health Plan, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were
improperly, negligently, or incompetently rendered), irrespective of legal theory, must be decided by binding arbitration under California law and not by
lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial
and accept the use of binding arbitration. I understand that the full arbitration provision is in the Health Plan’s coverage document, which is available for my
review.
☐ I have read and agree to the Binding Arbitration Agreement
ATTESTATION, ARBITRATION – read, complete & sign.
SIGN THE FORM AND SEND TO COVERED CALIFORNIA
Signature of Business Owner/Authorized Company Officer Title
Print Name Date
