THINGS TO KNOW
ATTENTION! If you are already enrolled on a CCSB plan, please use the Employee Change Request Form to update,
change, or terminate your existing CCSB coverage.
Ask your employer who to call with questions
• Online: 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
Your information is private.
We’ll keep your information private as required by law.
Your answers on this application will only be used to see if you are eligible to enroll in a Covered California
for Small Business plan.
If your share of the cost of employee-only coverage is more than 9.5% of
your household income, you may able to get help paying for coverage
through Covered California’s individual marketplace. Visit CoveredCA.com
to learn more.
Go online
Get help
What happens
next?
Alternatives
Visit CoveredCA.com/ForSmallBusiness. You’ll be able to see details about
Covered California’s small business health insurance marketplace.
You’ll return your completed, signed application to your employer. Your
employer will send us your completed, signed application.
NEED HELP WITH YOUR APPLICATION? Contact your employer or your employer’s Covered California Certified Insurance
Agent with questions, visit CoveredCA.com/ForSmallBusiness or call us at (855) 777-6782. Para obtener una copia de este
formulario en Español, llame (855) 777-6782.
Covered California for Small Business Employee Application | Rev. 3/17/2021
Covered California for
Small Business (CCSB)
Application for Employees
26. Are you of Hispanic/Latino, or Spanish origin? (OPTIONAL) Yes No If yes, check which one(s):
Page 1 of 5
Information about you, the employee.
Who is your employer?
Employer Name
Employer phone number
( )
1. First name, Middle name, Last name, & Suffix 2. Requested Coverage Effective Date 3. Are you a new hire?
4. Social Security Number or Tax ID Number 5. Date of birth (mm/dd/yyyy)
6. Home address 7. Apartment or suite
number
8. City 9. State 10. ZIP code 11. County
12. Mailing address (if dierent from home address) 13. Apartment or suite
number
14. City 15. State 16. ZIP code 17. County
18. Email address (OPTIONAL)
19. Phone number
21. Cal-COBRA/COBRA Applicants: 22. For CalCOBRA/COBRA applicants, indicate qualifying event :
Date of Qualifying Event: ________________________________________
Cell
Home
Work
Cal-COBRA
Cal-COBRA/COBRA effective date: __________________________________
(Cal-COBRA applicants must submit first month’s premium)
COBRA
23. Marital Status:
Single Domestic Partnership (DP)
Married
20. Other phone number
Cell
Yes No
Termination of employment
Reduction of hours
Divorce/Legal separation
Death of employee
Child no longer eligible
Medicare entitlement
Home
Work
( ) ( )
24. Preferred spoken or written language (OPTIONAL—if not English)
25. What is the preferred method of communication?
Mexican, Mexican American, Chicano
Puerto Rican
Salvadoran
Cuban
Guatemalan
Other Hispanic, Latino or Spanish
origin:
27. Race (OPTIONAL—Check all that apply.)
White American Indian or
Filipino
Chinese
Hmong
Vietnamese
Guamanian or Chamorro
Black or African
Alaska Native
Japanese
Laotian
Korean
Samoan
American Asian Indian
Native Hawaiian
Cambodian
Other
28. If you’re American Indian or Alaska Native, tell us the state and the name of your federally-recognized tribe (optional):
STEP 1
Tell us about your race Please tell us about yourself. This information is confidential and will only be used to make sure that everyone has
the same access to health care. It will not be used to decide what health insurance you qualify for.
NEED HELP WITH YOUR APPLICATION? Contact your employer or your employer’s Covered California
Certified Insurance Agent with questions, visit CoveredCA.com/ForSmallBusiness or call us at
(855) 777-6782. Para obtener una copia de este formulario en Español, llame (855) 777-6782.
continued on next page
Covered California for Small Business Employee Application | Rev.3/17/2021
Mail Email Phone
Not interested in CCSB health coverage?
If you don’t want CCSB health coverage from your employer, skip to Step 6 on page 4.
Please tell us about yourself and your eligible enrolling
dependents and indicate your CCSB Health Insurance
plan selection.
STEP 2
California law defines a dependent for health care coverage in the following way:
“Dependent” means the spouse or registered domestic partner, or child, of an eligible employee, subject to
applicable terms of the health care service plan contract covering the employee, and includes dependents
of guaranteed association members if the association elects to include dependents under its health
coverage at the same time it determines its membership composition.
My employer does not offer dependent coverage and I am interested in information on how I
can obtain other coverage for my dependents. I wish to have someone contact me to help me
understand my options.
Employer ____________________________________________________________________________________________________
Page 2 of 5
*Can be found in your selected plans provider directory.
EMPLOYEE
LAST NAME (FAMILY NAME) FIRST NAME M.I. SSN / TAX ID # GENDER (M/F)
GENDER (M/F)
GENDER (M/F)
GENDER (M/F)
GENDER (M/F)
HOME ADDRESS
MAILING ADDRESS
HOME ADDRESS MAILING ADDRESS
HOME ADDRESS MAILING ADDRESS
HEALTH PLAN
(See Appendix A)
BIRTHDATE MM / DD / YYYY
IF YES, IS YOUR PARTNERSHIP REGISTERED
WITH THE STATE OF CALIFORNIA? Y / N
ARE YOU A DOMESTIC
PARTNER? Y / N
SPOUSE
OR
DOMESTIC
PARTNER
BIRTHDATE MM / DD / YYYY
LAST NAME (FAMILY NAME) FIRST NAME M.I. SSN / TAX ID #
CHILD**
BIRTHDATE MM / DD / YYYY
LAST NAME (FAMILY NAME) FIRST NAME M.I. SSN / TAX ID #
IS CHILD BOTH DISABLED
AND 26 YEARS OLD OR
OLDER? Y / N
NEED HELP WITH YOUR APPLICATION? Contact your employer or your employer’s Covered California
Certified Insurance Agent with questions, visit CoveredCA.com/ForSmallBusiness or call us at
(855) 777-6782. Para obtener una copia de este formulario en Español, llame (855) 777-6782.
continued on next page
Covered California for Small Business Employee Application | Rev. 3/17/2021
HOME ADDRESS MAILING ADDRESS
CHILD**
BIRTHDATE MM / DD / YYYY
LAST NAME (FAMILY NAME) FIRST NAME M.I. SSN / TAX ID #
IS CHILD BOTH DISABLED
AND 26 YEARS OLD OR
OLDER? Y / N
HOME ADDRESS MAILING ADDRESS
CHILD**
BIRTHDATE MM / DD / YYYY
LAST NAME (FAMILY NAME) FIRST NAME M.I. SSN / TAX ID #
IS CHILD BOTH DISABLED
AND 26 YEARS OLD OR
OLDER? Y / N
**If you have more than 3 dependent children, please attach a separate sheet listing their required information and submit with this application.
DENTAL PLAN
(See Appendix A)
DENTAL PLAN
(See Appendix A)
DENTAL PLAN
(See Appendix A)
DENTAL PLAN
(See Appendix A)
DENTAL PLAN
(See Appendix A)
Signature of Applicant (or financially-responsible party if Applicant is under the age of 18)
Date (mm/dd/yyyy)
Print Name
COVERED CALIFORNIA binding arbitration agreement
STEP 3
Signature of Applicant Date (mm/dd/yyyy)
Read & sign this application.
STEP 5
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.
I know that my information on this form will only be used to determine eligibility for health coverage and will be kept private as
required by law. If I’m eligible, it will be used to help me enroll.
I know that I must tell Covered California for Small Business if anything changes from what I wrote on this application. I can call my
employer, my employer’s Covered California Certified Insurance Agent or call (877) 453-9198 to report changes.
I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation,
gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file.
Page 3 of 5
NEED HELP WITH YOUR APPLICATION? Contact your employer or your employer’s Covered California
Certified Insurance Agent with questions, visit CoveredCA.com/ForSmallBusiness or call us at
(855) 777-6782. Para obtener una copia de este formulario en Español, llame (855) 777-6782.
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.
continued on next page
Covered California for Small Business Employee Application | Rev. 3/17/2021
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 4
If a Certified Insurance Agent helped you complete this
application, please obtain their signature below.
Signature of Certified Insurance Agent
Print Name Date
Employer ____________________________________________________________________________________________________
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Covered by spouse’s/domestic partner’s group plan
I am declining medical coverage for (check all that apply):
Self
Spouse/Domestic Partner
Child(ren) Name(s) ______________________________________________________________________________________________________________
Reason for declining coverage:
Covered by individual policy Covered by Medi-Cal
Covered by Tricare Covered by other: ____________________________________________
Coverage is too expensive.
(You may want to contact Covered California at www.coveredca.com for
help in understanding available options and financial assistance in the
Covered California Individual Marketplace)
I am declining dental coverage for (check all that apply):
Self
Spouse/Domestic Partner
Child(ren) Name(s) ______________________________________________________________________________________________________________
Employee name
Signature of Employee Date (mm/dd/yyyy)
Complete this section if you are declining coverage from
your employer for you or your dependents.
STEP 6
Your employer will send us your application, and we will contact you if we need additional
information or to let you know you have been approved for coverage.
If you are not registered to vote where you live now and would like to apply to register to vote today please
visit registertovote.ca.gov or call 1-800-345-VOTE (8683).
Return your completed, signed application to your employer.
STEP 7
Covered by Medicare
Page 4 of 5
NEED HELP WITH YOUR APPLICATION?
Contact your employer or your employer’s Covered California
Certified Insurance Agent with questions, visit CoveredCA.com/ForSmallBusiness or call us at (855) 777-6782.
Para obtener una copia de este formulario en Español, llame (855) 777-6782.
Covered California for Small Business Employee Application | Rev. 3/17/2021
Employer ____________________________________________________________________________________________________
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 offered. 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.
Blue Shield
Health Net
Kaiser
Permanente
Sharp
Bronze 60 PPO
6300/65+ Child Dental
Bronze 60 PPO 6300/65
+ Child Dental
Bronze 60 HDHP PPO
7000/0% + Child Dental Alt
Bronze 60 HMO
6300/65
Bronze 60 HDHP HMO
7000/0%
Bronze 60 HMO
5400/60 Alt
Performance Bronze 60
HMO 6300/65 + Child
Dental
Premier Bronze 60
HDHP HMO 7000/0%
+ Child Dental
Gold 80 PPO 350/25
Silver 70 PPO
2250/50 + Child Dental
Trio Silver 70 HMO
2250/55 + Child Dental
+ Child Dental
Trio Gold 80 HMO 250/35
+ Child Dental
Platinum 90 PPO
0/15 + Child Dental
Trio Platinum 90 HMO
0/20 + Child Dental
Gold 80 HMO 250/35
Go
l
d 80 HMO 0/30 Alt
Gold 80 HMO 1000/40 Alt
Platinum 90 HMO 0/20
Platinum 90 HMO 0/10 Alt
Silver 70 HDHP PPO
1400/40% + Child Dental Alt
Gold 80 PPO 0/30
+ Child Dental Alt
Platinum 90 PPO 0/15+
Child Dental
EnhancedCare Platinum
90 PPO 250/15
+ Child Dental Alt
Silver 70 Value PPO
1700/50 + Child Dental Alt
Silver 70 PPO
2250/50 + Child Dental
EnhancedCare Silver
70 HDHP PPO 1400/40%
+ Child Dental Alt
EnhancedCare Silver
70 PPO 2250/55
+ Child Dental Alt
Gold 80 Value PPO 750/15
+ Child Dental Alt
EnhancedCare Gold 80
PPO 1000/30
Important: Please select ONE benefit plan from Medical and/or Dental Choices
by filling in the oval next to the selected plan(s).
Health Plan Bronze Silver Gold Platinum
Metal Tier
Health and Dental Plan Choices
APPENDIX A
Page 5 of 5
Performance Silver 70
HMO 2250/50 + Child
Dental
Premier Silver 70 HMO
2250/55 + Child Dental
Premier Silver 70 HDHP
HMO 2500/20%
+ Child Dental
Performance Gold 80
HMO 350/25 + Child
Dental
Premier Gold 80 HMO
250/35 + Child Dental
Performance Platinum 90
HMO 0/15 + Child Dental
Premier Platinum 90
HMO 0/20 + Child Dental
Delta Dental Childrens Dental HMO Family Dental HMO
Dental Health Services Family Dental HMO
Childrens Dental PPO Family Dental PPO
Dental Plan Pediatric Dental Plans Family Dental Plans **
California Dental Network Childrens Dental HMO Family Dental HMO
Liberty Dental Family Dental HMO
** Family dental plans offer both adult only and adult plus child coverage.
Covered California for Small Business Employee Application | Rev. 3/17/2021
* For health plans that do not include Child Dental, employees have the option to elect a standalone pediatric dental plan. Dependant children are eligible for Pediatric Dental coverage up to age 19.
Oscar
Circle Bronze 60 HDHP
EPO 7000/0% + Child
Dental
Circle Platinum 90 EPO
0/20 + Child Dental
Circle Gold 80 EPO
250/35 + Child Dental
Circle Gold 80 EPO 0/30
+ Child Dental Alt
+ Child Dental Alt
Gold 80 PPO 350/25
+ Child Dental
Silver 70 HMO 2250/55
Silver 70 HDHP HMO
2500/20%
Silver 70 HMO 1650/55 Alt
Silver 70 HMO 2100/55 Alt
Silver 70 HMO 2600/55 Alt
Circle Silver 70 EPO
2250/55 + Child Dental
Silver 70 EPO 1500/50
+ Child Dental Alt
Employee Name Employer Name
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
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.