Fillable Covered California for Small Business (CCSB) Complaint Form (Covered California)

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Covered California for Small Business (CCSB) Complaint Form (Covered California)

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The Covered California for Small Business (CCSB) Complaint Form (Covered California) form is 1 page long and contains:

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  • 7 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

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Covered California for Small Business (CCSB)
Complaint Form
Instructions:
Employers and employees may use this form to submit CCSB complaints. If filing a CCSB appeal, please
contact Customer Service at (855) 777-6782.
Your Information:
Case ID (optional)
First Name Last Name
Telephone Number (with area code)
Email Address
Street Address
City
State
ZIP Code
If you are filing a complaint against a Certified Insurance Agent, please provide agent information:
Agent Name
Agency Name
License Number
Telephone Number (with area
code)
City
State
ZIP Code
What area is your complaint regarding?
Call
center
Provider
Claim
Eligibility
Billing
Agent
Other
Tell us what happened and how we can help you (use extra paper if needed):
Mail this form to: Email this form: Call us at:
Covered California for Small Business CCSB@covered.ca.gov (855) 777-6782
1601 Exposition Blvd.
Sacramento, CA 95815
What happens next? Covered California will review your complaint and respond to you as soon as
possible.
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Covered California for Small Business (CCSB) Complaint Form (Covered California)

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Completed 19 May 2021

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