NEW EMPLOYEE Complete information below. EXISTING EMPLOYEE Complete only information that has changed.
4. HOME address 5. Apartment or suite number
6. City 7. State 8. ZIP code 9. County
10. MAILING address 11. Apartment or suite number
12. City 13. State 14. ZIP code 15. County
16. Email address (OPTIONAL) 17. Phone number Cell Home Work 18. Other phone number Cell Home Work
19. What is the preferred method of communication? Mail Email Phone
20. New First Name
21. New Last Name
Covered California for Small Business
Change Request Form for Employees 2020
For Effective Dates 1/1/2020 to 3/1/2020
Check here if changes are to be effective
at renewal.
Fax completed form to (949) 809-3264
Mail to Covered California at P.O. Box 7010, Newport Beach, CA 92658
For assistance call (855) 777-6782
Covered California for Small Business Change Request Form for Employees | Version CCSB V3.102219 2020-Q1
continued next page
Page 1 of 4
MARRIAGE OR DOMESTIC PARTNER ADDITION INDICATE DATE OF MARRIAGE OR DOMESTIC PARTNER DECLARATION
BIRTH, ADOPTION, GUARDIANSHIP, FOSTER CARE OR INDICATE DATE OF BIRTH, ADOPTION, GUARDIANSHIP, FOSTER CARE OR QUALIFIED
QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) MEDICAL CHILD SUPPORT ORDER
OF DEPENDENT CHILD
Employer name & address
Employer phone number Covered California for Small Business (CCSB) Group #
EMPLOYER INFORMATION
( ) -
NEED HELP WITH YOUR FORM? Contact your employer or your employer’s 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.
REASON FOR CHANGE CHECK ALL THAT APPLY
NEW HIRE INDICATE DATE COVERAGE WILL BE EFFECTIVE
PART-TIME TO FULL-TIME EMPLOYMENT CHANGE INDICATE DATE COVERAGE WILL BE EFFECTIVE
LOSS OR GAIN OF OTHER COVERAGE INDICATE DATE OF EFFECTIVE CHANGE AND PROVIDE LETTER FROM CARRIER OR EMPLOYER
NAME CHANGE/ADDRESS CHANGE INDICATE EFFECTIVE DATE OF CHANGE
EMPLOYEE INFORMATION
1. First name, Middle name, Last name & Sux 2. Date of Birth
3. Social Security Number or Tax ID Number
( ) -
( ) -
CHECK HERE IF NAME CHANGE
OR CORRECTION
GROUP OPEN ENROLLMENT MUST BE RECEIVED PRIOR TO RENEWAL DATE
EMPLOYER INFORMATION
DEPENDENT TERMINATION INDICATE EFFECTIVE DATE OF CHANGE
PLEASE PROVIDE THE DETAIL REGARDING YOUR CHANGE(S) IN THE RESPECTIVE SECTIONS THAT FOLLOW.
EFFECTIVE DATE
MMDDYYYY
CHANGE WILL BE EFFECTIVE
AT RENEWAL
Sex
Month Day Year
Check to Decline Coverage
You must also read and sign the Declination
Acknowledgement on Page 4.
Page 2 of 4
LAST NAME (FAMILY NAME)
BIRTHDATE MM/DD/YYYY
FIRST NAME MI SSN / TAX ID #
NAME OF HEALTH PLAN SELECTED
EMPLOYEE
ADD
CHANGE
CANCEL
ARE YOU A DOMESTIC PARTNER?
IF YES, IS THE PARTNERSHIP
REGISTERED WITH
THE STATE OF CALIFORNIA?
Employee Name Employer Name
CCSB Group
#
IMPORTANT! Plan changes are allowed during renewal and for employees who experience a qualifying event (i.e. newborn).
• CANCELLATIONS of coverage will take effect on the LAST DAY of the month AFTER RECEIPT of your request by Covered California. Cancellations at
renewal will take effect on the groups renewal date.
ADDITIONS (QUALIFYING EVENT): Please see your employer for effective date guidelines based on qualifying event.
ADDITIONS (AT RENEWAL): Coverage will be effective on the groups renewal date.
CHANGES (AT RENEWAL): If making any plan changes, please list all covered dependents.
This form must be received by Covered California NO LATER THAN 30 DAYS after the event takes place if outside renewal.
Please see the following page for
the available CCSB health and
dental plans to choose from.
continued next page
NEED HELP WITH YOUR FORM? Contact your employer or your employer’s 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.
COMPLETE THIS SECTION TO CANCEL COVERAGE, ADD DEPENDENTS OR CHANGE PLANS
NAME OF DENTAL PLAN SELECTED (OPTIONAL)
LAST DAY OF COVERAGE
LAST NAME (FAMILY NAME)
BIRTHDATE MM/DD/YYYY
FIRST NAME MI SSN / TAX ID #
SPOUSE
OR
DOMESTIC
PARTNER
ADD
CHANGE
CANCEL
REASON
LAST DAY OF COVERAGE
YES
NO
YES
NO
IS CHILD BOTH DISABLED AND 26 YEARS OR OLDER?
LAST NAME (FAMILY NAME)
BIRTHDATE MM/DD/YYYY
FIRST NAME MI SSN / TAX ID #
CHILD
ADD
CHANGE
CANCEL
REASON
LAST DAY OF COVERAGE
YES
NO
ADDRESS (IF DIFFERENT THAN EMPLOYEE) STREET CITY STATE ZIP
IS CHILD BOTH DISABLED AND 26 YEARS OR OLDER?
LAST NAME (FAMILY NAME)
BIRTHDATE MM/DD/YYYY
FIRST NAME MI SSN / TAX ID #
CHILD
ADD
CHANGE
CANCEL
REASON
LAST DAY OF COVERAGE
YES
NO
ADDRESS (IF DIFFERENT THAN EMPLOYEE) STREET CITY STATE ZIP
IS CHILD BOTH DISABLED AND 26 YEARS OR OLDER?
LAST NAME (FAMILY NAME)
BIRTHDATE MM/DD/YYYY
FIRST NAME MI SSN / TAX ID #
CHILD
ADD
CHANGE
CANCEL
REASON
LAST DAY OF COVERAGE
YES
NO
ADDRESS (IF DIFFERENT THAN EMPLOYEE) STREET CITY STATE ZIP
REASON
DENTAL PLAN SELECTED
DENTAL PLAN SELECTED
DENTAL PLAN SELECTED
DENTAL PLAN SELECTED
SEX
SEX
SEX
SEX
SEX
Covered California for Small Business Change Request Form for Employees | Version CCSB V3.102219 2020-Q1
Health Plan Bronze Silver Gold Platinum
Blue Shield
m
Bronze 60 PPO 6300/65
+ Child Dental
m
m
Silver 70 PPO 2250/50
+ Child Dental
Trio Silver 70 HMO 2250/50
+ Child Dental
m
m
Gold 80 PPO 250/25
+ Child Dental
Trio Gold 80 HMO 250/25
+ Child Dental
m
m
Platinum 90 PPO 0/15
+ Child Dental
Trio Platinum 90 HMO
0/15 + Child Dental
Health Net
m
Bronze 60 PPO 6300/65
+ Child Dental
m
Silver 70 HDHP PPO 1400/40%
+ Child Dental Alt
m
Gold 80 PPO 0/30
+ Child Dental Alt
m
Platinum 90 PPO 0/15
+ Child Dental
m
Bronze 60 HDHP PPO
5600/20% + Child Dental Alt
m
Silver 70 Value PPO 1700/50
+ Child Dental Alt
m
Gold 80 Value PPO
750/15 + Child Dental Alt
m
EnhancedCare Platinum
90 PPO 250/15
+ Child Dental Alt
m
EnhancedCare Bronze 60
HDHP PPO 5600/20%
+ Child Dental Alt
m
Silver 70 PPO 2250/50
+ Child Dental Alt
m
EnhancedCare Gold 80
PPO 1000/30
+ Child Dental Alt
m
EnhancedCare Silver 70 HDHP
PPO 1400/40% +Child Dental Alt
m
Gold 80 PPO 250/25
+ Child Dental
m
EnhancedCare Silver 70 PPO
2250/55 + Child Dental Alt
Kaiser Permanente
m
Bronze 60 HMO 6300/65
m
Silver 70 HMO 2250/50
m
Gold 80 HMO 250/25
m
Platinum 90 HMO 0/15
m
Bronze 60 HDHP HMO
6900/0%
m
m
m
Silver 70 HDHP HMO
2500/20%
Silver 70 HMO 1650/55 Alt
Silver 70 HMO 1800/55 Alt
m
Gold 80 HMO 500/30 Alt
m
Platinum 90 HMO 0/10
Alt
OSCAR
m
Bronze 60 HDHP EPO
6900/0% + Child Dental
m
Silver 70 EPO 2250/50
+ Child Dental
m
Gold 80 EPO 250/25
+ Child Dental
m
Platinum 90 EPO 0/15
+ Child Dental
m
Silver 70 EPO 1500/50
+ Child Dental Alt
m
Gold 80 EPO 0/30
+ Child Dental Alt
Sharp
m
Performance Bronze 60 HMO
6300/65 + Child Dental
m
Premier Silver 70 HMO
2250/50 + Child Dental
m
Performance Gold 80
HMO 250/25 + Child Dental
m
Performance Platinum 90
HMO 0/15 + Child Dental
m
Premier Bronze 60 HDHP
HMO 6900/0
+ Child Dental
m
Performance Silver 70 HMO
2250/50 + Child Dental
m
Premier Gold 80 HMO
250/25 + Child Dental
m
Premier Platinum 90 HMO
0/15 + Child Dental
m
Premier Silver 70 HDHP HMO
2500/20% + Child Dental
Page 3 of 4
Employee name Employer Name
CCSB Group #
IMPORTANT! Plan changes are only allowed at renewal. However, employees who experience a qualifying event (e.g. acquire a new dependent) are able to
change their coverage outside of the renewal period.
NOTE: Infertility benefits are available to employer groups when an Employer elects to provide this benefit during open enrollment or renewal periods. If an
employer with 20 or more full time employees elects to provide infertility benefits, all plans offered will include the this coverage.
If an employer with less than 20 full time employees elects to provide infertility benefits, only PPO and EPO plans will include this coverage. Infertility
benefits will not be included in HMO plans for groups with less than 20 full time employees.
METAL TIER
NEED HELP WITH YOUR FORM? Contact your employer or your employer’s 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.
NEW HEALTH AND DENTAL PLAN CHOICES
continued next page
** Family dental plans offer both adult only and adult plus child coverage.
*For health plans that do not include Child Dental, employees have the option to elect a standalone pediatric dental plan. Dependent children are eligible
for Pediatric Dental coverage up to age 19.
Plan selection varies by region. Please check with your employer for the list of available health plans in your area.
Covered California for Small Business Change Request Form for Employees | Version CCSB V3.102219 2020-Q1
Dental Plans
PEDIATRIC DENTAL PLANS FAMILY DENTAL PLANS**
California Dental Network
m
Children’s Dental HMO
m
Family Dental HMO
Delta Dental
m
Children’s Dental HMO
m
Children’s Dental PPO
m
Family Dental HMO
m
Family Dental PPO
Dental Health Services
m
Children’s Dental HMO
m
Family Dental HMO
Liberty Dental
m
Family Dental HMO
Page 4 of 4
COVERED CALIFORNIA 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 am signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my
knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.
Employee Name Employer Name
CCSB Group #
Signature of Employee Date (mm/dd/yyyy)
Employer Name
NEED HELP WITH YOUR FORM? Contact your employer or your employer’s 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.
SIGN THE FORM
Your employer will send us your form, and we will contact you if we need additional information or to let you know your request
for changes to your coverage have been approve
d.
RETURN YOUR COMPLETED, SIGNED FORM TO YOUR EMPLOYER
Signature of Employee Date (mm/dd/yyyy)
Employer Name
I acknowledge that the coverage available to me has been explained to me by my employer and I have the right to enroll
in the coverage oered. I have voluntarily decided not to enroll myself and/or my eligible dependent(s). By declining this
coverage I acknowledge that I and/or my eligible dependents will have to wait until my employer’s next open enrollment
period to enroll or change coverage, unless eligible for a special enrollment period through a qualifying event.
DECLINATION ACKNOWLEDGEMENT
CERTIFIED INSURANCE AGENT INFORMATION
Certified Insurance Agent Name Email Phone Number
Please tell us the Certied Insurance Agent who assisted you with your Covered California for Small Business health coverage.
I did not receive assistance from a Certied Insurance Agent.
Covered California for Small Business Change Request Form for Employees | Version CCSB V3.102219 2020-Q1
STOP! ONLY complete and sign below if you are declining coverage.
!
I am declining medical coverage for (check all that apply):
Self
Spouse / Domestic Partner
Child(ren) Name(s)
Reason for declining coverage (choose one):
m
Covered by spouse’s / domestic partner’s group plan
m
Covered by individual policy
m
Covered by Tricare
m
Covered by Medicare
m
Covered by Medi-Cal
m
Covered by Other:
m
Coverage is too expensive. (You may want to contact Covered CA at
www.coveredca.com for help in understanding the available options
andnancialassistanceintheCoveredCaIndividualMarketplace)
I am declining dental coverage for (check all that apply):
Self
Spouse / Domestic Partner
Child(ren) Name(s)