Fillable Small Business Master Group Application (Dickerson Insurance Services)

Fill Online, Printable, Fillable, Blank Small Business Master Group Application (Dickerson Insurance Services) Form

Use Fill to complete blank online DICKERSON INSURANCE SERVICES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Small Business Master Group Application (Dickerson Insurance Services)

On average this form takes 67 minutes to complete

The Small Business Master Group Application (Dickerson Insurance Services) form is 9 pages long and contains:

  • 0 signatures
  • 130 check-boxes
  • 207 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Dickerson Insurance Services forms online.

BROWSE DICKERSON INSURANCE SERVICES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
C153 8 5 (7/21) 1 of 9
Small Business Master Group Application
Effective July 1, 2021
Blue Shield of California and
Blue Shield of California Life & Health Insurance Company Requested Coverage Effective Date: ____________________
Use this form if you currently don't have any Blue Shield Small Business coverage, or to add medical to existing specialty coverage.
Please type or print clearly in black ink.
1A EMPLOYER INFORMATION
Group legal name Federal Tax ID (TID) number
Doing business as (DBA), if applicable: Standard Industry Classification (SIC) and industry description
Principal business address in California – number and street (no P.O. box)*
City State ZIP code
Billing address (if different from above)
City State ZIP code
Location of group headquarters
(if different from “Principal business address in California” above) – number and street (no P.O. box)*
City State ZIP code County
* The principal business address means the principal business address registered with the Secretary of the State of California. If a principal business address is not
registered with the State or is registered solely for purposes of service of process and is not a substantial worksite for the group's business, then provide the
business address within the State where the greatest number of employees work.
1B GROUP CONTACT INFORMATION
Only the primary contact can access group information.
Primary
contact
Name Title
Phone Email
Secondary
contact
Name Title
Phone Email
c
Check here to register the primary contact for online account access to view and/or manage the group account.
Once registered, the primary group contact can delegate account access to the group's producer or other individuals
within the company. To sign up or make account changes, please visit blueshieldca.com/employer.
Blue Shield of California is an independent member of the Blue Shield Association C15385-FF (7/21)
C15 3 85 (7/21) 2 of 9
1C LEGAL ENTITY TYPE
Choose one legal entity type:
c
S-Corporation
c
C-Corporation
c
Partnership or LP
c
Sole proprietor
c
LLC
c
Non-profit
c
Other (specify) _________________________________________________________________________
1D AFFILIATED COMPANIES AND SUBSIDIARIES
When counting the number of employees or eligible employees to determine if the group is a "small employer", companies
that are affiliated companies and that are eligible to file a combined tax return for purposes of state taxation are considered
one employer.
Does the group have any subsidiary or affiliated companies?
c
Yes
c
No
Subsidiary or affiliated company name(s)
Include in
coverage?
Eligible to file a combined
state tax return?
c
Yes
c
No
c
Yes
c
No
c
Yes
c
No
c
Yes
c
No
c
Yes
c
No
c
Yes
c
No
2A PREVIOUS AND CURRENT COVERAGE
If the group has had or currently has medical coverage, who was/is the most recent carrier(s)? ______________________________
Is the group intending to offer Blue Shield alongside another carrier?
c
Yes
c
No
If yes, carrier name ________________________________ Number of employees enrolled ________
2B CONTINUATION COVERAGE
If the group is subject to continuation coverage, choose one option below:
c
Federal COBRA, OR
20+ total employees, employed 50% working days in previous calendar year.
c
Cal-COBRA
2-19 eligible employees, employed 50% working days in previous calendar year; or if not in the
business during the previous calendar year, during the previous calendar quarter.
Provide information below for all Federal COBRA and/or Cal-COBRA employees:
Number of
current enrollees
Number of employees
and/or family members
in election period
Enrollment forms
submitted for all
enrolling participants?
Federal COBRA
c
Yes
c
No
Cal-COBRA
c
Yes
c
No
Reset
Reset
Reset
C15 3 85 (7/21) 3 of 9
3A EMPLOYEE COUNTS
__________
Total number of employees – count all full-time and part-time employees, regardless of eligibility for
coverage, including employed owners and officers
__________
Eligible employees*
Total number of eligible full-time employees
c
Yes
c
No
Is the group offering coverage to part-time employees? See definition of part-time employee below.
If yes, __________ Total number of eligible part-time employees
Total number of eligible enrolling/refusing employees – the counts of enrolling and refusing should equal the total number
of eligible employees entered above.
ENROLLING
Medical
coverage __________
Dental
coverage __________
Vision
coverage __________
Life
coverage __________
REFUSING
Medical
coverage __________
Dental
coverage __________
Vision
coverage __________
Life
coverage __________
* Eligible Employee – use this definition to determine which employees are eligible to enroll, and remain enrolled, in coverage. An eligible employee is an employee who:
• (Full-time) Is a permanent employee who works on a full-time basis in the conduct of the business of the employer, whose duties are performed at the
employer’s regular place(s) of business, working an average of 30 hours per work week, and who has met any statutorily authorized waiting period; or
• (Part-time) Meets all the conditions set forth in the first bullet except works at least 20 hours but no more than 29 hours at least 50% of the weeks in the previous
calendar quarter, the group offers such employees health coverage and all similarly situated employees are offered such coverage; and
• Receives monetary compensation in the course of employment (shown through W-2); and
• Is a bona fide employee and a bona-fide employee/employer relationship exists.
• An eligible employee also includes a sole proprietor, spouse, or Domestic Partner of a sole proprietor, or partners of a partnership, or the spouse or Domestic
Partner of a partner of a partnership working on a full-time basis at the employer’s regular place(s) of business, working an average of 30 hours per work week,
when the group meets all small employer eligibility requirements.
• An eligible employee does not include individuals working on a temporary or substitute basis.
3B GROUP ELIGIBILITY
c
Yes
c
No
Is the group actively engaged in business or service?
A "Yes" answer means the business currently provides goods or services.
A "No" answer means the business does not currently provide goods or services.
c
Yes
c
No
Was the group formed primarily for the purpose of buying health coverage?
A "Yes" answer means the business was established solely to obtain healthcare coverage, not to provide
goods or services.
A "No" answer means the business was established solely to provide goods or services.
c
Yes
c
No
Did the group employ 1-100 employees on at least 50% of its working days during the preceding
calendar quarter or preceding calendar year (unless the group is a startup), the majority of whom
reside within the state of CA, and in which a bona fide employer-employee relationship exists?
c
Yes
c
No
Does your group employ at least one W-2 ("common law”) employee listed on the employer's DE 9C, who
meets the definition of an “eligible employee”, who isn’t the sole proprietor, a partner of the partnership,
or their spouse or registered domestic partner?
Use the method for counting full time employees (FTE) and FTE Equivalents described in Section 4980H(c)(2) of the Internal
Revenue Code to determine if the group is a “small employer” under the Small Group Act. A group must employ 1-100 total
FTEs, including FTE Equivalents, (not including sole proprietors, partners of a partnership, their spouses or legal domestic
partners), to be eligible for a small group health plan at issuance and renewal, in addition to meeting any applicable
underwriting criteria such as contribution and participation requirements.
To calculate the number of FTEs and FTE Equivalents:
• FTE: an FTE is an employee who has on average at least 30 hours of service per week, or at least 130 hours of service total,
during a calendar month.
• FTE Equivalent: this calculation is to account for employees who average fewer than 30 hours of service per week, who,
in combination, are counted as the equivalent of a full-time employee.
• FTE Equivalent employee calculation: combine the number of hours of service of all non-full-time employees for the month
(do not include more than 120 hours of service per employee). Divide the total number by 120. If the result is a fraction,
round down.
Total current FTE and FTE Equivalent ______
If current count is larger than 100, how many employed in prior
calendar quarter? ______
If prior calendar quarter count is larger than 100, how many
employed in prior calendar year? ______
Total current FTE and FTE
Equivalent employed out of state ______
Total FTE and FTE Equivalent employed out of state during the prior
calendar quarter ______
Total FTE and FTE Equivalent employed out of state during the prior
calendar year ______
C15 3 85 (7/21) 4 of 9
4 ADDITIONAL GROUP INFORMATION
c
Yes
c
No
Are all eligible employees being offered health coverage? (Employees who waive coverage
on the grounds that they have group coverage through another employer are not counted as
eligible employees).
c
Yes
c
No
Do all employees and their dependents who are to be covered by the plan contract work or
reside in the service area in which the plan provides or otherwise arranges for the provision of
health services?
c
Yes
c
No
Are all employees covered by workers’ compensation to the extent required by law?
c
Yes
c
No
Does the group employ both union and non-union employees?
c
Yes
c
No
Has the group used employees leased from a Professional Employer Organization (PEO) within the
past six weeks?
A leased employee is employed and paid by the PEO. When the PEO performs administrative
services only, such as payroll processing, the employees are not leased.
c
Yes
c
No
If yes, are you canceling this leasing arrangement and hiring employees?
c
Yes
c
No
Is the group a spinoff?*
c
Yes
c
No
Is the group a startup?
†
* Spinoff Group – a newly formed business in which a majority of the employees of the new business have left an established business (“former business”) which
had been offering Blue Shield coverage to its employees. At least 50% of the employees in the spin-off group must have been enrolled in Blue Shield through
the former business. The new group must not have shared ownership with the former business. Contact your sales representative for more information.
† Startup Group – has been in business and has employed at least one eligible common-law employee for less than six weeks and otherwise meets all small
employer requirements.
5 EMPLOYER ORIENTATION AND WAITING PERIODS
An employer may impose a bona fide employment-based orientation (affiliation) period for new employees which cannot
exceed 30 days. If the employer imposes an orientation period when completing an enrollment form for a new employee,
the “date of hire” is the first day after completion of the orientation period.
A waiting period may also be imposed before coverage becomes effective, beginning the first day after any orientation period
and not to exceed 90 days.
Choose one of the following options. Coverage for eligible employees will become effective following completion of the
waiting period on the day specified.
c
Effective first of the month following date of hire (if hired on the first of the month, coverage will
be effective the first of the following month)
c
Effective first of the month following 30 days from date of hire
c
Effective first of the month following 60 days from date of hire
c
Effective on the 91st day following date of hire
(a group may be partially billed when electing the 91st day waiting period)
c
Yes
c
No
Does the group intend to offer coverage to employees currently in the employer waiting period for
the original effective date of the group contract (i.e. one-time waiver of employer waiting period)?
6 NOTICES AND ELECTRONIC DISTRIBUTION OF MATERIALS
• Summary of Benefits and Coverage (SBC) forms are available for all health plans. These forms summarize coverage and
benefits for all plans in a uniform manner. Log in to blueshieldca.com/policies to review SBC forms for any plan prior to
submitting an application. Once the group’s application for coverage is approved, download the SBC form(s) for benefit
plans specific to your group at bscadocs.com/sbc to distribute to employees.
• The group is responsible for the prompt distribution of the Evidence of Coverage booklets and other required coverage
notices ("required materials") to covered employees. Electronic versions of required materials are emailed directly to the
group administrator. For printed versions of required materials, please contact us at (800) 559-5905.
C15 3 85 (7/21) 5 of 9
7A MEDICAL PLANS
For groups with one or more enrolling employee, choose plans from either the Off-Exchange or Mirror plan packages,
but not both. Plan packages cannot be combined. Within a plan package, HMO and PPO can be offered together.
Off-Exchange
Package
May be offered with another carrier’s HMO plan
Mirror
Package
Cannot be offered alongside Off-Exchange plans or any other carrier’s plans. These plans “mirror”
standardized plans offered through Covered California
Blue Shield of California Off-Exchange Package for Small Business
PPO Plans
Full PPO and Tandem PPO have different provider networks. Full PPO and Full HSA-compatible High Deductible
Health Plan (HDHP) plans share a full Blue Shield provider network. Tandem PPO and Tandem HSA-compatible
HDHP plans share a select Blue Shield provider network. Choose any combination of Full PPO Network and
Tandem PPO Network plans.
c
Choose ALL PPO plans, OR
c
Individually choose any number of the plan(s) below:
PPO plans – Full PPO Network
c
Platinum Full PPO 0/0 OffEx
c
Platinum Full PPO 0/10 OffEx
c
Platinum Full PPO 250/10 OffEx
c
Platinum Full PPO 250/15 OffEx
c
Gold Full PPO 0/25 OffEx
c
Gold Full PPO 500/30 OffEx
c
Gold Full PPO 750/30 OffEx
c
Gold Full PPO 1200/35 OffEx
c
Silver Full PPO 1950/50 OffEx
c
Silver Full PPO 2225/50 OffEx*
c
Silver Full PPO 2400/55 OffEx
c
Bronze Full PPO 6250/70 OffEx
c
Bronze Full PPO 6850/65 OffEx
c
Bronze Full PPO 7500/50 OffEx
HSA-compatible HDHP plans – Full PPO Network
c
Gold Full PPO Savings 1750/15% OffEx
c
Silver Full PPO Savings 2100/25% OffEx
c
Silver Full PPO Savings 2600/35% OffEx
c
Bronze Full PPO Savings 5700/40% OffEx
c
Bronze Full PPO Savings 7000 OffEx
HSA-compatible HDHP plans –
Tandem PPO Network
c
Gold Tandem PPO Savings 1750/15% OffEx
c
Silver Tandem PPO Savings 2100/25% OffEx
c
Silver Tandem PPO Savings 2600/35% OffEx
c
Bronze Tandem PPO Savings 5700/40% OffEx
c
Bronze Tandem PPO Savings 7000 OffEx
Tandem PPO plans – Tandem PPO Network
c
Platinum Tandem PPO 0/0 OffEx
c
Platinum Tandem PPO 0/10 OffEx
c
Platinum Tandem PPO 250/10 OffEx
c
Platinum Tandem PPO 250/15 OffEx
c
Gold Tandem PPO 0/25 OffEx
c
Gold Tandem PPO 500/30 OffEx
c
Gold Tandem PPO 750/30 OffEx
c
Gold Tandem PPO 1200/35 OffEx
c
Silver Tandem PPO 1950/50 OffEx
c
Silver Tandem PPO 2225/50 OffEx*
c
Silver Tandem PPO 2400/55 OffEx
c
Bronze Tandem PPO 6250/70 OffEx
c
Bronze Tandem PPO 6850/65 OffEx
c
Bronze Tandem PPO 7500/50 OffEx
* The Silver Full PPO 2225/50 OffEx and Silver Tandem PPO 2225/50 OffEx offer enhanced coverage for members diagnosed with diabetes, asthma, COPD, and CAD.
HMO Plans
Access+ HMO plans, Local Access+ HMO plans, and Trio HMO plans have different provider networks.
Local Access+ and Trio are select networks and Access+ is a full network. Access+ and Local Access+
networks may not be offered together.
c
Choose ALL Trio and Local Access+ plans, OR
c
Choose ALL Trio and Access+ plans, OR
c
Individually choose any number of plan(s) below from Trio/Access+ or Trio/Local Access+:
Access+ HMO plans –
Access+ HMO Network
c
Platinum Access+ HMO 0/20 OffEx
c
Platinum Access+ HMO 0/25 OffEx
c
Platinum Access+ HMO 0/30 OffEx
c
Gold Access+ HMO 0/30 OffEx
c
Gold Access+ HMO 500/35 OffEx
c
Gold Access+ HMO 1000/35 OffEx
c
Gold Access+ HMO 1500/35 OffEx
c
Silver Access+ HMO 2350/65 OffEx
Trio HMO plans –
Trio ACO HMO Network
c
Platinum Trio HMO 0/20 OffEx
c
Platinum Trio HMO 0/25 OffEx
c
Platinum Trio HMO 0/30 OffEx
c
Gold Trio HMO 0/30 OffEx
c
Gold Trio HMO 500/35 OffEx
c
Gold Trio HMO 1000/35 OffEx
c
Gold Trio HMO 1500/35 OffEx
c
Silver Trio HMO 2350/65 OffEx
Local Access+ HMO plans –
Local Access+ HMO Network
c
Platinum Local Access+ HMO 0/20 OffEx
c
Platinum Local Access+ HMO 0/25 OffEx
c
Platinum Local Access+ HMO 0/30 OffEx
c
Gold Local Access+ HMO 0/30 OffEx
c
Gold Local Access+ HMO 500/35 OffEx
c
Gold Local Access+ HMO 1000/35 OffEx
c
Gold Local Access+ HMO 1500/35 OffEx
c
Silver Local Access+ HMO 2350/65 OffEx
Blue Shield of California Mirror Package for Small Business
c
Choose ALL Trio HMO and Full PPO plans, OR
c
Individually choose any number of plan(s) below from Trio HMO and/or Full PPO
Platinum Mirror plans
c
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental
c
Blue Shield Platinum 90 PPO 0/15 + Child Dental
Gold Mirror plans
c
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental
c
Blue Shield Gold 80 PPO 350/25 + Child Dental
Silver Mirror plans
c
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental
c
Blue Shield Silver 70 PPO 2250/50 + Child Dental
Bronze Mirror plans
c
Blue Shield Bronze 60 PPO 6300/65 + Child Dental
Reset
Reset
Reset
C15 3 85 (7/21) 6 of 9
7B ADDITIONAL SELECTIONS
Choose any additional selections, as applicable.
c
Yes, HealthEquity
If you selected an HDHP plan, you may choose to make HealthEquity your HSA administrator.
Choosing HealthEquity means Blue Shield shares eligibility and claims data for a seamless
experience. If you do not select HealthEquity, please work directly with your own
HSA administrator.
c
Yes, Infertility Rider
If selected, a rider for infertility benefits will be added to all medical plans for the entire
group. This rider can be offered with either an off-exchange or a mirror plan package,
HMO and PPO.
8A SPECIALTY BENEFITS – DENTAL
Choose one dental plan option below:
c
Single dental plan option – choose any ONE plan below (HMO or PPO), OR
c
Dual Choice dental plan option – choose any TWO plans below (any combination of HMO or PPO), OR
c
Triple Choice dental plan option – choose THREE plans below in one of these combinations:
c
2 Dental HMO and 1 Dental PPO, OR
c
3 Dental HMO plans, OR
c
2 Dental PPO plans and 1 Dental HMO plan – This option requires you to offer Blue Shield medical plans.
The 2 Dental PPO plans must have the same Ortho benefit.
Dental HMO plans
c
DHMO Basic
c
DHMO Standard
c
DHMO Plus
c
DHMO Deluxe
c
DHMO Voluntary
Dental PPO plans
c
Smile
SM
Value 50/1500/No Ortho/MAC/NR
c
Smile
SM
50/1500/No Ortho/MAC/NR
c
Smile
SM
Plus 50/1500/Ortho/MAC/NR
c
Smile
SM
Basic 75/1000/No Ortho/MAC/NR
c
Smile
SM
Basic 50/1000/No Ortho/MAC
c
Smile
SM
Basic 50/1000/Ortho/U85
c
Smile
SM
Plus 50/1500/No Ortho/MAC
c
Smile
SM
Plus 50/1500/No Ortho/MAC/WP*
c
Smile
SM
Deluxe 50/1500/Ortho/MAC/NR
c
Smile
SM
Deluxe 2000 50/2000/No Ortho/MAC/NR
c
Smile
SM
Deluxe Plus 2000 50/2000/Ortho/MAC/NR
c
Smile
SM
Deluxe Gold 50/1500/Ortho/U85/NR
c
Smile
SM
Plus Gold 50/1500/Ortho/U85/NR
c
Smile
SM
Plus Gold 50/1500/Ortho/U80
c
Smile
SM
Plus Gold 50/1500/No Ortho/U80
c
Smile
SM
Plus Gold 50/1500/Ortho/U80/ADV
c
Smile
SM
Plus Gold 50/1500/Ortho/U90/ADV
c
Smile
SM
Plus Gold 50/1500/No Ortho/U90/ADV
c
Smile
SM
Plus Gold 50/2500/Ortho/U90/ADV
c
Smile
SM
Plus Gold 50/2500/No Ortho/U90/ADV
c
Ultimate Dental PPO for Small Business 50/2000/No Ortho/
MAC/NR
c
Ultimate Dental Plus PPO for Small Business 50/2000/Ortho/
MAC/NR
c
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U80
c
Ultimate Dental PPO for Small Business 50/2000/Lifetime Ortho/U90
c
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U90
Voluntary Dental PPO plans*
c
Smile
SM
Basic Voluntary 75/1000/No Ortho/MAC/NR
c Smile
SM
Basic Voluntary 50/1000/No Ortho/MAC
c Smile
SM
Basic Voluntary 50/1500/Ortho/U80
c Smile
SM
Basic Voluntary 50/1000/No Ortho/U80 (No Wait)
†
* Voluntary Dental plans require one eligible, enrolling employee.
† This Voluntary plan does not include Waiting Periods. Submission of proof of any prior coverage is not required.
ADV stands for Advantage. ADV plans incentivize members to use in-network providers.
NR stands for No Rollover.
Reset
C15 3 85 (7/21) 7 of 9
8B SPECIALTY BENEFITS – VISION*
Choose one vision plan option below:
c
Single vision plan option – choose any ONE plan below, OR
c
Dual Choice vision plan option – choose any TWO plan options below:
Ultimate Vision for
Small Business (12-12-12)
Preferred Vision for
Small Business (12-12-24)
Basic Vision for
Small Business (12-24-24)
c
Ultimate Vision Plus 0/0/150/120
c
Preferred Vision Plus 0/0/150/120
c
Basic Vision Plus 0/0/150/120
c
Ultimate Vision 0/0/150
c
Preferred Vision 0/0/150
c
Basic Vision 0/0/150
c
Ultimate Vision Plus 10/25/150/120
c
Preferred Vision Plus 10/25/150/120
c
Basic Vision Plus 10/25/150/120
c
Ultimate Vision 10/25/150
c
Preferred Vision 10/25/150
c
Basic Vision 10/25/150
c
Ultimate Vision 0/0/120
c
Preferred Vision 0/0/120
c
Basic Vision 0/0/120
c
Ultimate Vision 10/25/120
c
Preferred Vision 10/25/120
c
Basic Vision 10/25/120
c
Ultimate Vision Voluntary 10/25/150
c
Preferred Vision Voluntary 10/25/120
c
Basic Vision Voluntary 10/25/120
Voluntary Vision plans require one eligible, enrolling employee.
* Vision plans are underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).
8C SPECIALTY BENEFITS – LIFE/AD&D*
Choose the life plan design and coverage amount from the options below:
1. Select plans – Choose one employee plan option: Flat, Multiple of salary, or Graded. Determine if you also want to offer
dependent life. If offering dependent life, the group must also offer Employee Life/AD&D.
2. Provide benefit details – Use the “Benefit amounts table” at the bottom of this section to find available amounts for each
plan type.
Employee
1. Select plan(s) 2. Provide benefit details Description
c
Flat
Benefit amount: $ _____________
All employees are covered at the same flat amount
(up to the maximum amount).
c Multiple
of salary
c 1x salary or
c 2x salary
Up to a
maximum benefit of: $ _____________
All employees are covered for the same multiple of
salary at one or two times annual salary (up to the
maximum amount). Benefit amounts are rounded
to the next highest $1,000.
c Graded
Make selections in the “Graded life
table” below
Employees are covered by class (up to four), defined
with different levels of benefits. Classes can be either
flat or multiple of salary, and this selection can vary
for each class.
c Dependent
Benefit amount: $ _____________
Only available to employees electing Life/AD&D.
Benefits for children ages 14 days to six months are 10%
of total benefit, with no coverage for infants from birth
to 14 days. AD&D is not available for dependents.
Graded life table (use only if choosing a graded plan). Provide a class description and choose one plan option, Flat or Multiple
of Salary, for each class. Plan choices may vary by class. The benefit amount for each class must be no more than
2.5 times that of the next lower class.
Provide class description Flat Multiple of salary
Up to
four classes
Provide
benefit amount
Select salary
multiplier
Provide maximum
benefit amount
Class 1
$ _____________
c 1x or c 2x
$ _____________
Class 2
$ _____________
c 1x or c 2x
$ _____________
Class 3
$ _____________
c 1x or c 2x
$ _____________
Class 4
$ _____________
c 1x or c 2x
$ _____________
Reset
Reset
C15 3 85 (7/21) 8 of 9
Benefit amount table (use to find benefit amount or maximum benefit for your plan type)
Number
of eligible
employees
Flat Multiple of salary Basic dependent life
If benefit is within a
range, pick any
increment of $5,000.
Minimum benefit always
$15,000. 1x or 2x annual salary
up to the below maximums.
Dependent life benefit must not be
more than 50% of the employee
benefit. spouse/domestic partner
and children must be covered for
the same benefit amount.
2-9 $15,000 – $50,000 $30,000 or $50,000
$1,000 or $2,000 or $3,000
or $4,000 or $5,000
10-24 $15,000 – $100,000
$50,000 – $300,000 for 1x annual
salary and $50,000 – $500,000
for 2x annual salary
$1,000 or $2,000 or $3,000 or
$4,000 or $5,000 or $7,500
or $10,000 or $20,000
25-50 $15,000 – $150,000
$50,000 – $300,000 for 1x annual
salary and $50,000 – $500,000
for 2x annual salary
51-100
$15,000 – $150,000 or
$175,000 or $200,000
$50,000 – $300,000 for 1x annual
salary and $50,000 – $600,000
for 2x annual salary
Employee Life/AD&D requires two eligible, enrolling employees.
* Life/AD&D Insurance is underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).
9 EMPLOYER CONTRIBUTIONS
How much will the group contribute for each product selected?
Medical
Employee: __________ % or $ __________
Employer must contribute either (1) at least
50% of employee’s total premium, or (2) a defined
contribution minimum of $100 per employee (or the
cost of total employee premiums, whichever is less).
If employer pays 100% employee premium, all eligible
employees must enroll in coverage.
Dependent: __________ % or $ __________
Dental
Employee: __________ % or $ __________
Employer must contribute at least 50% of employee's
total premium (except for voluntary plans). If 100% is
paid by the employer, all eligible employees must enroll
in coverage.
Dependent: __________ % or $ __________
Vision
Employee: __________ % or $ __________
Employer must contribute at least 25% of employee’s
total premium (except for voluntary plans). If 100% is
paid by the employer, all eligible employees must enroll
in coverage.
Dependent: __________ % or $ __________
Basic Term Life
and AD&D
Employee: __________ % or $ __________
Employer must contribute at least 25% of employee’s
total premium. If 100% is paid by the employer
(non-contributory), all eligible employees must enroll
in coverage. Voluntary life is not an option.
Dependent: __________ % or $ __________
C15 3 85 (7/21) 9 of 9
10A
PRODUCER INFORMATION (to be completed by producer or general agent)
Producer agency name (as associated to Tax ID Number) Producer Tax ID number (for commission payments)
Producer name (agent who wrote the group) Producer CDI license number
Producer email
Producer phone number
Producer address – number and street (no P.O. Box)
City State ZIP code
Does the producer have a delegate contact? c
Yes
c
No
If yes, delegate name Delegate email
Is there a split commission? c
Yes
c
No
If yes, 1st Producer __________% 2nd Producer __________%
2nd producer name 2nd producer Tax ID
10B
GENERAL AGENT INFORMATION (to be completed by producer or general agent, if applicable)
General agency name (as associated to Tax ID Number) General agency Tax ID number (for commission payments)
General agency contact name General agency contact email
10C
PRODUCER SIGNATURE (to be completed by producer or general agent)
c
I assisted the applicant in completing and submitting this application. I certify that, to the best of my knowledge and belief,
the information on this application is complete and accurate. I explained to the applicant, in easy-to-understand language,
the risk to the applicant of providing inaccurate information, and the applicant understood the explanation.
Date (required)
__________________________________
Producer signature (required)
X_____________________________________
Producer printed name (required)
_____________________________________
11 EMPLOYER ATTESTATIONS AND SIGNATURE
c
The group representative attests to the following:
1. Each employee to whom coverage is being offered meets the definition of an eligible employee (see Section 3A of this
application for reference).
2. This is an application for coverage. The group understands that no contract for coverage will exist until Blue Shield has
completed its review and communicated to the applicant or the applicant’s broker that the application has been
accepted, required premium payments have been made, and a group health service contract has been issued. The group
representative certifies that, to the best of his/her knowledge and belief, all of the responses provided in this application are
true, correct, and complete.
3. By signing below, the group also understand that if it has committed fraud or made an intentional misrepresentation of
any material fact in conjunction with this application within the first 24 months of issuance of coverage, Blue Shield may
pursue one of the following remedies: Coverage may be cancelled or the applicable dues/premiums may be adjusted, or
following notice, the health service contract may be rescinded.
Authorized group representative signature
Date
Authorized group representative printed name
Authorized group representative printed title
Blue Shield of California
Notice Informing Individuals about Nondiscrimination
and Accessibility Requirements
Discrimination is against the law
Blue Shield of California complies with applicable state laws and federal civil rights laws, and does
not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status,
gender, gender identity, sexual orientation, age, or disability. Blue Shield of California does not
exclude people or treat them differently because of race, color, national origin, ancestry, religion,
sex, marital status, gender, gender identity, sexual orientation, age, or disability.
Blue Shield of California:
• Provides aids and services at no cost to people with disabilities to communicate effectively
with us such as:
- Qualified sign language interpreters
- Written information in other formats (including large print, audio, accessible electronic
formats, and other formats)
• Provides language services at no cost to people whose primary language is not English such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact the Blue Shield of California Civil Rights Coordinator.
If you believe that Blue Shield of California has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, ancestry, religion, sex, marital status,
gender, gender identity, sexual orientation, age, or disability, you can file a grievance with:
Blue Shield of California
Civil Rights Coordinator
P.O. Box 629007
El Dorado Hills, CA 95762-9007
Phone: (844) 831-4133 (TTY: 711)
Fax: (844) 696-6070
Email: BlueShieldCivilRightsCoordinator@blueshieldca.com
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our
Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the
U.S. Department of Health and Human Services, Office for Civil Rights electronically through the
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
(800) 368-1019; TTY: (800) 537-7697
Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
Blue Shield of California
601 12
th
Street, Oakland CA 94607
Blue Shield of California is an independent member of the Blue Shield Association
A20275 (12/19)
blueshieldca.com
Notice of the Availability of Language Assistance Services
Blue Shield of California
IMPORTANT: Can you read this letter? If not, we can have somebody help you read it.
You may also be able to get this letter written in your language. For help at no cost, please
call right away at the Member/Customer Service telephone number on the back of your
Blue Shield ID card, or (866) 346-7198.
IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla.
También puede recibir esta carta en su idioma. Para ayuda sin cargo, por favor llame
inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de
su tarjeta de identificación de Blue Shield o al (866) 346-7198. (Spanish)
重要通知：您能讀懂這封信嗎？如果不能，我們可以請人幫您閱讀。這封信也可以 用您所講的語言書寫。
如需免费幫助，請立即撥打登列在您的Blue Shield ID卡背面上的 會員/客戶服務部的電話，或者撥打
電話 (866) 346-7198。(Chinese)
QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý
vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ
miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue Shield
của quý vị hoặc theo số (866) 346-7198. (Vietnamese)
MAHALAGA: Nababasa mo ba ang sulat na ito? Kung hindi, maari kaming kumuha ng
isang tao upang matulungan ka upang mabasa ito. Maari ka ring makakuha ng sulat na
ito na nakasulat sa iyong wika. Para sa libreng tulong, mangyaring tumawag kaagad sa
numerong telepono ng Miyembro/Customer Service sa likod ng iyong Blue Shield ID kard,
o (866) 346-7198. (Tagalog)
Baa’ ákohwiindzindoo7g7: D77 naaltsoos7sh y77niłta’go b77n7ghah? Doo b77n7ghahgóó é7, naaltsoos nich’8’
yiid0o[tah7g77 ła’ nihee hól=. D77 naaltsoos a[d0’ t’11 Din4 k’ehj7 1dooln77[ n7n7zingo b7ighah. Doo b22h 7l7n7g0
sh7k1’ adoowo[ n7n7zing0 nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 Blue Shield bee n47ho’d7lzin7g7
bine’d44’ bik11’ 47 doodag0 47 (866) 346-7198 j8’ hod77lnih. (Navajo)
중요: 이 서신을 읽을 수 있으세요? 읽으실 수 경우, 도움을 드릴 수 있는 사람이 있습니다. 또한 다른
언어로 작성된 이 서신을 받으실 수도 있습니다. 무료로 도움을 받으시려면 Blue Shield ID 카드 뒷면의
회원/고객 서비스 전화번호 또는 (866) 346-7198로 지금 전환하세요. (Korean)
Կ
Կ
Ա
Ա
Ր
Ր
Ե
Ե
Վ
Վ
Ո
Ո
Ր
Ր
Է
Է
․
․
Կարողանում ե՞ք կարդալ այս նամակը։ Եթե ոչ, ապա մենք կօգնենք ձեզ։ Դուք պետք է
նաև կարողանաք ստանալ այս նամակը ձեր լեզվով։ Ծառայությունն անվճար է։ Խնդրում ենք
անմիջապես զանգահարել Հաճախորդների սպասարկման բաժնի հեռախոսահամարով, որը նշված է
ձեր Blue Shield ID քարտի ետևի մասում, կամ (866) 346-7198 համարով։ (Armenian)
ВАЖНО:
Не можете прочесть данное письмо? Мы поможем вам, если необходимо. Вы также можете
получить это письмо написанное на вашем родном языке. Позвоните в Службу клиентской/членской
поддержки прямо сейчас по телефону, указанному сзади идентификационной карты Blue Shield, или
по телефону (866) 346-7198, и вам помогут совершенно бесплатно. (Russian)
重
重
要
要
：
：
お客様は、この手紙を読むことができますか？ もし読むことができない場合、弊社が、お客様
をサポートする人物を手配いたします。 また、お客様の母国語で書かれた手紙をお送りすることも可
能です。 無料のサポートを希望される場合は、Blue Shield IDカードの裏面に記載されている会員/お客
様サービスの電話番号、または、(866) 346-7198にお電話をおかけください。 (Japanese)
blueshieldca.com
:ﻢﮭﻣ ﯽﻣ ﺎﯾآﯽﻣ ،ﺖﺳا ﯽﻔﻨﻣ نﺎﺘﺨﺳﺎﭘ ﺮﮔا ؟ﺪﯿﻧاﻮﺨﺑ ار ﮫﻣﺎﻧ ﻦﯾا ﺪﯿﻧاﻮﺗﯽﻣ ﯽﺘﺣ .ﻢﯿھد راﺮﻗ نﺎﺗرﺎﯿﺘﺧا رد ﺎﻤﺷ ﮫﺑ ﮏﻤﮐ یاﺮﺑ ار ﯽﺴﮐ ﻢﯿﻧاﻮﺗ ﮫﺨﺴﻧ ﺪﯿﻧاﻮﺗ
زا ﺖﻗو تﻮﻓ نوﺪﺑ
ً
ﺎﻔﻄﻟ ،نﺎﮕﯾار ﮏﻤﮐ ﺖﻓﺎﯾرد یاﺮﺑ .ﺪﯿﻨﮐ ﺖﻓﺎﯾرد نﺎﺗدﻮﺧ نﺎﺑز ﮫﺑ ار ﮫﻣﺎﻧ ﻦﯾا بﻮﺘﮑﻣ ﯽﺳﺎﻨﺷ ترﺎﮐ ﺖﺸﭘ رد ﮫﮐ ﯽﻨﻔﻠﺗ هرﺎﻤﺷ ﻖﯾﺮط
Blue Shield ﻦﻔﻠﺗ هرﺎﻤﺷ ﻖﯾﺮط زا ﺎﯾ و ﺖﺳا هﺪﺷ جرد نﺎﺗ7198-346 )866.ﺪﯾﺮﯿﮕﺑ سﺎﻤﺗ یﺮﺘﺸﻣ/ﺎﻀﻋا تﺎﻣﺪﺧ ﺎﺑ ( (Persian)
:        ?               
                     
Blue Shield ID     /    ,  (866) 346-7198    (Punjabi)
 ?   
  
 /   Blue Shield
  (866) 346-7198 (Khmer)
: ﻢﮭﻤﻟا اﺬھ ﻰﻠﻋ لﻮﺼﺤﻟا ﻰﻟإ
ً
ﺎﻀﯾأ جﺎﺘﺤﺗ ﺪﻗ .ﮫﺗءاﺮﻗ ﻲﻓ كﺪﻋﺎﺴﯿﻟ ﺎﻣ ﺺﺨﺷ رﺎﻀﺣإ ﺎﻨﻨﻜﻤﯾ ،ﮫﺗءاﺮﻗ ﻊﻄﺘﺴﺗ ﻢﻟ نأ ؟بﺎﻄﺨﻟا اﺬھ ةءاﺮﻗ ﻊﯿﻄﺘﺴﺗ ﻞھ
ﺎﺠﻟا ﻰﻠﻋ نوﺪﻤﻟا ءﺎﻀﻋﻷا ﺪﺣأ/ءﻼﻤﻌﻟا ﺔﻣﺪﺧ ﻒﺗﺎھ ﻢﻗر ﻰﻠﻋ نﻵا لﺎﺼﺗﻻا ﻰﺟﺮﯾ ،ﺔﻔﻠﻜﺗ نوﺪﺑ ةﺪﻋﺎﺴﻤﻟا ﻰﻠﻋ لﻮﺼﺤﻠﻟ .ﻚﺘﻐﻠﺑ
ً
ﺎﺑﻮﺘﻜﻣ بﺎﻄﺨﻟا ﻲﻔﻠﺨﻟا ﺐﻧ
ﺔﯾﻮﮭﻟا ﺔﻗﺎﻄﺑ ﻦﻣBlue Shield ﻢﻗﺮﻟا ﻰﻠﻋ وأ7198-346 )866.((Arabic)
TSEEM CEEB: Koj pos tuaj yeem nyeem tau tsab ntawv no? Yog hais tias nyeem tsis tau, peb tuaj yeem nrhiav ib tug
neeg los pab nyeem nws rau koj. Tej zaum koj kuj yuav tau txais muab tsab ntawv no sau ua koj hom lus. Rau kev pab
txhais dawb, thov hu kiag rau tus xov tooj Kev Pab Cuam Tub Koom Xeeb/Tub Lag Luam uas nyob rau sab nraum nrob
qaum ntawm koj daim npav Blue Shield ID, los yog hu rau tus xov tooj (866) 346-7198. (Hmong)
สําคัญ: 


 
  Blue Shield 
(866) 346-7198 (Thai)
महवप
ू
ण:       
?  ,    
        

     
   
:
       Blue Shield ID 
   
/   ,  (866) 346-7198   
(Hindi)
ສ
ສ
ິິ
່່
ງງສສ
ໍໍ
າາຄຄ
ັັ
ນນ: ທ
່
ານສາມາດອ
່
ານຈ
ົ
ດໝາຍນ
ີ
້
ໄດ
້
ບ
ໍ
? ຖ
້
າອ
່
ານບ
ໍ
່
ໄດ
້
, ພວກເຮ
ົ
າສາມາດໃຫ
້
ບາງຄ
ົ
ນຊ
່
ວຍອ
່
ານໃຫ
້
ທ
່
ານຟ
ັ
ງໄດ
້
.
ທ
່
ານຍ
ັ
ງສາມາດຂ
ໍ
ໃຫ
້
ແປຈ
ົ
ດໝາຍນ
ີ
້
ເປ
ັ
ນພາສາຂອງທ
່
ານໄດ
້
.ສ
ໍ
າລ
ັ
ບຄວາມຊ
່
ວຍເຫ
ຼ
ື
ອແບບບ
ໍ
່
ເສຍຄ
່
າ, ກະລ
ຸ
ນາ
ໂທຫາເບ
ີ
ໂທຂອງຝ
່
າຍບ
ໍ
ລ
ິ
ການສະມາຊ
ິ
ກ/ລ
ູ
ກຄ
້
າໃນທ
ັ
ນທ
ີ
ເບ
ີ
ໂທລະສ
ັ
ບຢ
ູ
່
ດ
້
ານຫ
ຼ
ັ
ງບ
ັ
ດສະມາຊ
ິ
ກ Blue Shield ຂອງທ
່
ານ,
ຫ
ຼ
ື
ໂທໄປຫາເບ
ີ
(866) 346-7198. (Laotian)
blueshieldca.com
Notice of the Availability of Language Assistance Services
Blue Shield of California Life & Health Insurance Company
No Cost Language Services. You can get an interpreter. You can get documents read to you
and some sent to you in your language. For help, call us at the number listed on your ID card or
1-866-346-7198. For more help call the CA Dept. of Insurance at 1-800-927-4357.
English
Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le
envíen algunos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de
identificación o al 1-866-346-7198. Para obtener más ayuda, llame al Departamento de Seguros de
CA al 1-800-927-4357.
Spanish
免
免
費
費
語
語
言
言
服
服
務
務
。您可獲得口譯員服務。可以用中文把文件唸給您聽，有些文件有中文的版本，也可以把這些文
件寄給您。欲取得協助，請致電您的保險卡所列的電話號碼，或撥打
1-866-346-7198
與我們聯絡。欲取得其他
協助，請致電
1-800-927-4357
與加州保險部聯絡。
Chinese
Các Dịch Vụ Trợ Giúp Ngôn Ngữ Miễn Phí. Quý vị có thể được nhận dịch vụ thông dịch. Quý vị có thể được
người khác đọc giúp các tài liệu và nhận một số tài liệu bằng tiếng Việt. Để được giúp đỡ, hãy gọi cho chúng tôi
tại số điện thoại ghi trên thẻ hội viên của quý vị hoặc 1-866-346-7198. Để được trợ giúp thêm, xin gọi Sở Bảo
Hiểm California tại số 1-800-927-4357.
Vietnamese
무료
통역
서비스
.
귀하는
한국어
통역
서비스를
받으실
수
있으며
한국어로
서류를
낭독해주는
서비스를
받으실
수
있습니다
.
도움이
필요하신
분은
귀하의
ID
카드에
나와있는
안내
전화
: 1-866-346-7198
번으로
문의해
주십시오
.
보다
자세한
사항을
문의하실
분은
캘리포니아
주
보험국
,
안내
전화
1-800-927-4357
번으로
연락해
주십시오
.
Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at
maipababasa mo sa Tagalog ang mga dokumento. Para makakuha ng tulong, tawagan kami sa
numerong nakalista sa iyong ID card o sa 1-866-346-7198. Para sa karagdagang tulong, tawagan
ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
Անվճար
Լեզվական
Ծառայություններ։
Դուք
կարող
եք
թարգման
ձեռք
բերել
և
փաստաթղթերը
ընթերցել
տալ
ձեզ
համար
հայերեն
լեզվով։
Օգնության
համար
մեզ
զանգահարեք
ձեր
ինքնության
(ID)
տոմսի
վրա
նշված
կամ
1-866-346-7198
համարով։
Լրացուցիչ
օգնության
համար
1-800-927-4357
համարով
զանգահարեք
Կալիֆորնիայի
Ապահովագրության
Բաժանմունք։
Armenian
Беслпатные услуги перевода. Вы можете воспользоваться услугами переводчика, и ваши
документы прочтут для вас на русском языке. Если вам требуется помощь, звоните нам по
номеру, указанному на вашей идентификационной карте, или 1-866-346-7198. Если вам
требуется дополнительная помощь, звоните в Департамент страхования штата Калифорния
(Department of Insurance), по телефону 1-800-927-4357.
Russian
無
無
料
料
の
の
言
言
語
語
サ
サ
ー
ー
ビ
ビ
ス
ス
日本語で通訳をご提供し、書類をお読みします。サービスをご希望の方は、ＩＤカー
ド記載の番号または
1-866-346-7198
までお問い合わせください。更なるお問い合わせは、カリフォルニア州
保険庁、
1-800-927-4357
までご連絡ください。
Japanese
ﺧ تﺎﻣﺪﻧﺎﺠﻣﯽ نﺎﺑز ﮫﺑ طﻮﺑﺮﻣ. ﺪﻧﻮﺷ هﺪﻧاﻮﺧ نﺎﺘﯾاﺮﺑ ﯽﺳرﺎﻓ نﺎﺑز ﮫﺑ کراﺪﻣ ﺪﯿﺋﻮﮕﺑ و ﺪﯿﻨﮐ هدﺎﻔﺘﺳا ﯽھﺎﻔﺷ ﻢﺟﺮﺘﻣ ﮏﯾ تﺎﻣﺪﺧ زا ﺪﯿﻧاﻮﺘﯿﻣ. ی ا ﺮ ﺑ
هرﺎﻤﺷ ﻦﯾا ﺎﯾ و ﺖﺳا هﺪﺷ ﺪﯿﻗ ﺎﻤﺷ ﯽﺋﺎﺳﺎﻨﺷ ترﺎﮐ یور ﮫﮐ ﯽﻨﻔﻠﺗ هرﺎﻤﺷ ﻖﯾﺮط زا ﺎﻣ ﺎﺑ،ﮏﻤﮐ ﺖﻓﺎﯾرد1-866-346-7198 ﺪﯾﺮﯿﮕﺑ سﺎﻤﺗ. یاﺮﺑ
ﮫﺑ ،ﺮﺘﺸﯿﺑ ﮏﻤﮐ ﺖﻓﺎﯾردCA Dept. of Insurance ) ﺎﯿﻧﺮﻔﯿﻟﺎﮐ ﮫﻤﯿﺑ هرادا ( هرﺎﻤﺷ ﮫﺑ1-800-927-4357 ﺪﯿﻨﮐ ﻦﻔﻠﺗ.Persian
blueshieldca.com
ਮੁਫ਼ਤ
ਭਾਸ਼ਾ
ਸੇਵਾਵਾਂ
:





























(ID)

'



'


1-866-346-7198 '

'











1-800-927-4357 '



Punjabi





    

1-866-346-7198

  

1-800-927-4357
Khmer
ﺔﻘﻠﻜﺗ نوﺪﺑ ﺔﻤﺟﺮﺗ تﺎﻣﺪﺧ. ﻐﻠﻟﺎﺑ ﻚﻟ ﻖﺋﺎﺛﻮﻟا ةءاﺮﻗ و ﻢﺟﺮﺘﻣ ﻲﻠﻋ لﻮﺼﺤﻟا ﻚﻨﻜﻤﯾﺔﯿﺑﺮﻌﻟا ﺔ . ﻞﺼﺗا ،ةﺪﻋﺎﺴﻤﻟا ﻲﻠﻋ لﻮﺼﺤﻠﻟ
ﻢﻗﺮﻟا ﻲﻠﻋ وأ ﻚﺘﯾﻮﻀﻋ ﺔﻗﺎﻄﺑ ﻲﻠﻋ ﻦﯿﺒﻤﻟا ﻢﻗﺮﻟا ﻲﻠﻋ ﺎﻨﺑ1-866-346-7198 . ،تﺎﻣﻮﻠﻌﻤﻟا ﻦﻣ ﺪﯾﺰﻤﻟا ﻲﻠﻋ لﻮﺼﺤﻠﻟ
ﻢﻗﺮﻟا ﻲﻠﻋ ﺎﯿﻧرﻮﻔﯿﻟﺎﻛ ﺔﯾﻻﻮﻟ ﻦﯿﻣﺄﺘﻟا ةرادﺈﺑ ﻞﺼﺗا1-800-927-4357.
Arabic
Cov Kev Pab Txhais Lus Tsis Them Nqi. Koj yuav thov tau kom muaj neeg los txhais lus rau koj thiab kom
neeg nyeem cov ntawv ua lus Hmoob. Yog xav tau kev pab, hu rau peb ntawm tus xov tooj nyob
hauv koj daim yuaj ID los sis 1-866-346-7198. Yog xav tau kev pab ntxiv hu rau CA lub Caj Meem Fai
Muab Kev Tuav Pov Hwm ntawm 1-800-927-4357
Hmong
 










1-866-346-7198



 

1-800-927-4357
Thai


































,

ID






,

1-866-346-7198











(CA Dept. of Insurance)

1-800-927-4357



Hindi
Doo b11h 7l7n7g0 saad bee y1t’i’ bee an1’1wo’. D77 sh1 ata’halne’doo7g7 h0l=-doo n7n7zingo 47 b7ighah. Naaltsoos
naanin1h1jeeh7g7 shich’8’ y7idooltah 47 doodag0 [a’ shich’8’ 1dooln77[ n7n7zingo b7ighah. Sh7k1 a’doowo[ n7n7zingo
nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 ninaaltsoos doot[‘7zh7g7 bee n47ho’d7lzin7g7 bine’d44’ bik11’ 47 doodag0
47 (866)346-7198j8’ hod77lnih. H0zh= sh7k1 an11’doowo[ n7n7zingo 47 d77 b4eso 1ch’22h naa’nil bi[ haz’32j8’
1-800-927-4357j8’ hod77lnih.
Navajo
ບບ
ໍໍ
ລລ
ິິ
ກກາານນແແປປພພາາສສາາໂໂດດຍຍບບ
ໍໍ
່່
ເເສສຍຍຄຄ
່່
າາ. ທ
່
ານສາມາດຂ
ໍ
ເອ
ົ
າຜ
ູ
້
ແປພາສາໄດ
້
. ທ
່
ານສາມາດຂ
ໍ
ໃຫ
້
ອ
່
ານເອກະສານໃຫ
້
ທ
່
ານຟ
ັ
ງ
ແລະ ສ
ົ
່
ງເອກະສານບາງຢ
່
າງທ
ີ
່
ເປ
ັ
ນພາສາຂອງທ
່
ານ. ສ
ໍ
າລ
ັ
ບຄວາມຊ
່
ວຍເຫ
ຼ
ື
ອ, ໃຫ
້
ໂທຫາພວກເຮ
ົ
າຕາມເບ
ີ
ໂທລະສ
ັ
ບທ
ີ
່
ມ
ີ
ໃນບ
ັ
ດປະຈ
ໍ
າຕ
ົ
ວຂອງທ
່
ານ ຫ
ຼ
ື
ໂທຫາເບ
ີ
1-866-346-7198. ສ
ໍ
າລ
ັ
ບຄວາມຊ
່
ວຍເຫ
ຼ
ື
ອເພ
ີ
່
ມເຕ
ີ
ມໂທຫາ ພະແນກ ປະກ
ັ
ນໄພຂອງ
ລ
ັ
ດຄາລ
ີ
ຟ
ໍ
ເນຍໄດ
້
ທ
ີ
່
ເບ
ີ
1-800-927-4357.
Laotian
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Small Business Master Group Application (Dickerson Insurance Services)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document