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Covered California for Small Business (CCSB) (Dickerson Insurance Services)

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Covered California
for Small Business (CCSB)
Application for Employers
Who can use this
What you will
need to apply
application?
What happens
next?
Get help
THINGS TO KNOW
Covered California for Small Business offers a new way for
small employers to offer health insurance to employees.
To be eligible to participate in CCSB, you must indicate that your
business or organization meets all of these qualifications:
• Have a primary business address in California, or offer coverage to each
eligible employee through CCSB servicing that employee’s primary worksite,
• Have 1 to 100 Full-Time Equivalent (FTE) employees*, and
• Offer coverage through CCSB to all full-time employees, that average
30+ hours per week
• A copy of your reconciled DE-9C
• Additional business
documentation (see Step 1)
• Eligible employee information
- Full name
- Social Security Number or
Tax Identification Number
- Date of birth
Your information is private.
• We’ll keep your information private as required by law.
• Your answers on this form will only be used to see if your business or organization is eligible for CCSB and,
if eligible, to facilitate enrollment.
✔
You’ll send this form and your employees’ completed, signed applications
to the address on page 6. You’ll hear back from us within 1–2 weeks. We’ll
let you know if you’re eligible to buy insurance for your small business.
• Online: www.CoveredCA.com/ForSmallBusiness
• Phone: Call our Service Center at (855) 777-6782
• En Español: Llame a nuestro centro de ayuda gratis al (855) 777-6782
• Contact your Certified Insurance Agent
• Contact the Covered California for Small Business
Service Center for information on how to find a Certified
Insurance Agent (855) 777-6782
- Home address
- Phone number
- COBRA/Cal-COBRA status
- Dependent information
(if offering dependent coverage)
Employees who decline coverage must
still complete an employee application
and sign the appropriate section of
the application.
Covered California for Small Business Employer Application | Effective date 01/01/2020 — Rev. 9/18/19
* Please refer to page 3 for more information regarding Full-Time Equivalent (FTE) employees and how to arrive at this calculation.
Local Business License
or
DE-9C
or
Fictitious Business Name Filing Payroll Records for 30 Days
Schedule C
or
DE-9C
and
Statement of Information (if Officers are
offered coverage and not listed on DE-9C)
or
Corporate Meeting minutes listing
all officers names
DE-9C
Document 1 (Choose one) Document 2 (Choose one) Document 3 (Choose one)
You must provide the following:
Less than 3 months
You are a:
And have been in
business for:
Sole Proprietor
Partnership
3 months or more
Corporation
Limited Liability
Partnership (LLP)
Limited Liability
Company (LLC)
Limited Part
nership
(LP)
Page 1 of 6
STEP 1
To verify eligibility for CCSB:
Articles of Incorporation
(Filed and Stamped)
Current Schedule K-1 (if Partners
are not listed on DE-9C)
or
Partnership Agreement and Fed Tax
ID Appointment letter (if Schedule
K-1 not available yet)
Schedule C (if owner is enrolling)
DE-9C
or
Payroll Records for 30 Days
Less than 3 months
3 months or more
DE-9C
or
Payroll records for 30 days
DE-9C
Partnership Agreement
Statement of Information (if Officers
are offered coverage and not listed
on DE-9C)
Federal Tax ID Appointment letter
Less than 3 months
3 months or more
You must provide the following:
Local Business License or
Fictitious Business License
Current Schedule K-1 (if General
Partners are not listed on DE-9C)
or
Partnership Agreement and Fed Tax
ID Appointment letter (if Schedule
K-1 not available yet)
DE-9C
or
Payroll records for 30 days
DE-9C (Limited Partners of a LP are
not eligible for coverage unless
they appear on a DE-9C)
Partnership Agreement
Federal Tax ID Appointment letter
Less than 3 months
3 months or more
Current Schedule K-1 (if Partners
are not listed on DE-9C)
or
Partnership Agreement and Fed Tax
ID Appointment letter (if Schedule
K-1 not available yet)
DE-9C
Partnership Agreement
or
Federal Tax ID Appointment letter
DE-9C
or
Payroll Records for 30 Days
Less than 3 months
3 months or more
Current Schedule K-1 for partnership
or a Schedule C for sole proprietorship
(if managing members are not listed
showing wages on DE-9C)
or
Statement of Information or Articles
of Organization with Operating
Agreement (if no Schedule K-1 or
Schedule C)
DE-9C
Articles of Organization with
Operating Agreement
or
Statement of information
DE-9C
or
Payroll Records for 30 Days
Less than 3 months
3 months or more
Covered California for Small Business Employer Application | Effective date 01/01/2020 — Rev. 9/18/19
continued on next page ➡
Sole Proprietors
are eligible for
coverage through
CCSB if they have
eligible employees.
Dickerson Insurance Services Authorized
GA BIN #370846
1918 Riverside Dr., Los Angeles, CA 90039
Page 2 of 6
Employers must have a primary business address in California, or offer coverage to each eligible employee
through CCSB servicing that employee’s primary worksite.
Private Nonprofit Government Church/church affiliated
Business legal name DBA
1. Business legal name 2. Federal Employer Identification Number (FEIN)
4. State Employer Identification Number (SEIN)
3. Doing business as (DBA)
5. Which name do you want to use for reporting purposes? 6. Organization type
10. SIC code
7. Total number of Full-Time
Equivalent (FTE) employees*?
8. Total number of eligible employees? 9. Requested Coverage Effective Date
11. I’m offering health coverage to:** 12.
Yes, I’m offering coverage to
non-registered domestic partners.
No, I’m not offering coverage to
non-registered domestic partners.
13. My company is subject to:
15a. Do you currently offer
health coverage?
Federal COBRA Cal-COBRA
STEP 2
Tell us about your business.
Tell us who to contact about this application.
STEP 3
NEED HELP WITH YOUR APPLICATION? Contact your Certified Insurance Agent with questions – visit www.CoveredCA.com,
or call us at (855) 777-6782.
Covered California for Small Business Employer Application | Effective date 01/01/2020 — Rev. 9/18/19
Primary Contact (official communications will be addressed to the primary contact)
1. First name, Last name, & Suffix
Authorized Representative (if you want to name someone as your authorized representative — OPTIONAL)
6. First name, Last name, & Suffix
7. Phone number 8. Email address (OPTIONAL)
3. Email address
2. Phone number
Mail Email Phone
( )
–
( )
–
4. What is the preferred method of communication? 5. Preferred spoken or written language (OPTIONAL—if not English)
Company Addresses
9. Principal business address – street address 1 (must be a California street address)
10. Street address 2
11. City 12. State 13. ZIP code 14. County
18. City 19. State
20. ZIP code
21. County
Yes No
15. Is your mailing address the same as your principal business address?
17. Mailing address
Yes No
16. Is your billing address the same as your principal business address?
23. City 24. State 25. ZIP code 26. County
22. Billing address
continued on next page ➡continued on next page ➡
14. Have you employed 20 or more employees for 20 or more
weeks during the current or preceding calendar year?
Yes No
Yes No Not Eligible
* Please refer to page 3 for more information regarding Full-Time Equivalent (FTE) employees and how to arrive at this calculation.
**
If an employer is considered as an Applicable Large Employer (total of 50 or more FTE employees), the employer will need to offer dependent
children coverage to their employees in order to avoid the Employer Shared Responsibility (ESR) penalties. Please refer to Section 4980H
of the Internal Revenue Code.
Employee Only
Yes
No
15b. If yes, with which carrier(s)? 16. Do you intend to take advantage of the
Small Business Health Care Tax Credit?
Employee + Child(ren) Employee + Spouse/DP + Child(ren)
Employee + Spouse/Domestic Partner (DP)
Agent Information (if applicable)
1. First name, Middle name, Last name, & Suffix
5. General agency name (if applicable)
2. CA insurance license # 3. Agency FEIN #
4. Covered California Certified Insurance Agent
Yes No
Dickerson Insurance Services
For the purposes of determining whether an employer is a small or large employer as defined by the Affordable Care Act (ACA)
and applicable California law, the employer is required to calculate its total number of “Full-Time Equivalent” (FTE) employees.
This number determines whether the employer is eligible to participate in Covered California for Small Business. The FTE
number is also important for determining whether an employer is an Applicable Large Employer (ALE) and subject to the
Employer Shared Responsibility Provisions (ESRP) under Section 4980H of the Internal Revenue Code.
An FTE employee is not an actual employee but a calculation involving all part-time and full-time employees who worked during
the preceding calendar year. See Health and Safety Code Section 1357.500(k)(3) and Insurance Code Section 10965.3(q)(3) for
further information. If the employer did not exist in the prior calendar year or calendar quarter, the employer shall determine
the average number of employees who are reasonably expected to work on business days in the current calendar year. That
figure will establish whether the employer is eligible for coverage through Covered California for Small Business.
For purposes of determining whether an employer is an Applicable Large Employer that is subject to the ESRP, the calculation
only involves the employment figures from the prior calendar year. See Section 4980H of the Internal Revenue Code and the
IRS website for more details.
Instructions
1. Information on how to perform the FTE calculation:
http://hbex.coveredca.com/toolkit/forsmallbusiness/CCSB_%2016_%20ALE_FAQs_FINAL.pdf
2. Employer Shared Responsibility Provision (ESRP) Estimator:
http://taxpayeradvocate.irs.gov/estimator/esrp/
3. Use the final FTE figures as the number you use to fill in Step 2, question 7 of this application.
Important to Know:
• If your FTE number is at least 50, you are required to offer coverage to all dependent children up to the age of 26.
See Section 4980H of the Internal Revenue Code.
• Calculating the total FTE number is your responsibility as an employer.
• Covered California cannot provide assistance with the FTE calculation. Please consult with a Certified Insurance Agent
or visit the IRS website for assistance.
Page 3 of 6
What is a full-time equivalent employee?
continued on next page ➡
Covered California for Small Business Employer Application | Effective date 01/01/2020 — Rev. 9/18/19
STEP 8
Specify premium contribution.
Enter the percentage amount you will contribute toward:
Employee premium ______________ % (50% minimum)
Dependent premium _____________ % (optional, enter “0” if no contribution)
STEP 4
Select one plan level to offer to your employees.
OR, you may offer your employees the opportunity to select from
two plan levels:
Bronze Silver Gold Platinum
Bronze/Silver Silver/Gold Gold/Platinum
STEP 5
Infertility
Do you want to offer coverage plans that includes infertility coverage?
Page 4 of 6
continued on next page ➡
Covered California for Small Business Employer Application | Effective date 01/01/2020 — Rev. 9/18/19
Yes No
STEP 7
Select reference plan within your selected plan level(s).
(The reference plan is the plan you choose to determine the amount you will contribute
toward your employee premiums.)
STEP 6
Dental Coverage
Health Insurance Carrier _____________________________________________________________________________________________________________________
Reference Plan Name (be as specific as possible) ___________________________________________________________________________________________
In Plan Level
Bronze Silver Gold Platinum
See below for rules about infertility coverage offerings:
Employers with 20 or more FTE’s:
• Employers with 20 or more full-time equivalent (FTE) employees who choose to offer Infertility benefits to their employees,
all products shall include Infertility benefits.
• Employers with 20 or more FTE employees who choose to not offer Infertility benefits to their employees, all products shall
not include Infertility benefits.
Employers with less than 20 FTE’s:
Employers with less than 20 FTE employees have the option to include Infertility benefits only on Non-HMO plans.
If Employer chooses to offer Infertility benefits, the following applies:
• Employees selecting an HMO product cannot select a plan with Infertility benefits.
• Employees selecting either a PPO or EPO product must select a plan with Infertility benefits.
If Employer chooses to not offer Infertility benefits, the following applies:
• Employees electing an HMO product cannot select a plan with Infertility benefits.
• Employees electing either a PPO or EPO product cannot select a plan with Infertility benefits.
Yes No
Do you want to offer dental coverage?
continued on next page ➡
STEP 9
Attestation, Arbitration & Signature – read, complete & sign
Page 5 of 6Covered California for Small Business Employer Application | Effective date 01/01/2020 — Rev. 9/18/19
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 SHOP will not consider my group coverage
approved until SHOP has received 85 percent of the first month's premium payment.
E. I know that SHOP will not consider my group coverage approved until SHOP 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 SHOP.
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 SHOP, 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 SHOP 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 SHOP 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 SHOP at any time.
L. I understand that the attestations in this section must be maintained in order for my group to continue coverage through SHOP.
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
Signature of Business Owner/Authorized Company Officer
Print Name
Title
Date
STEP 12
Mail the completed application & your employee applications.
Mail your completed application, including all employee applications and other required documents to:
Covered California for Small Business
P.O. Box 7010
Newport Beach, CA 92658
For overnight deliveries, send to:
Covered California for Small Business Service Center
15525 Sand Canyon Avenue
Irvine, CA 92618
Page 6 of 6
Need help?
If you have questions about this application or need help completing it, contact your
Covered California Certified Insurance Agent, or call (855) 777-6782.
Para obtener una copia de este formulario en Español, llame (855) 777-6782.
STEP 11
Did you...
…read the Full-Time Equivalent (FTE) employee guidance on page 3?
...read and sign page 5?
...attach all required documentation from page 1?
...complete the information for all eligible employees (if including an employee roster)?
...obtain your Certified Insurance Agent’s signature?
Note: Covered California will send you an invoice for your first month of premium.
I did not use a Certified Insurance Agent.
The applicant completed and executed this application, and I assisted the applicant by offering advice in providing
responses to questions. I advised the applicant that he/she should answer all such questions completely and
truthfully and that no information requested should be withheld. I explained to the applicant, in easy-to-under-
stand language, the risk to the applicant of providing inaccurate information and the applicant understood the
explanation. To the best of my knowledge, based on what the applicant disclosed to me, the information in this
application is accurate and complete. I understand that if any portion of this statement signed by me is false,
I may be subject to civil penalties of up to $10,000 as authorized under California Health and Safety Code
Section 1389.8 and Insurance Code Section 10119.3.
STEP 10
If a Certified Insurance Agent helped you complete this
application, please obtain their signature below.
Signature of Certified Insurance Agent
Print Name Date
Covered California for Small Business Employer Application | Effective date 01/01/2020 — Rev. 9/18/19
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Completed 1 June 2021

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