Small Business Owner Eligibility Statement
Company name:
Entity type: c Sole proprietor c Corporation c LLC c Partnership c LP c LLP
c
Other
If you are a shareholder, member, officer, or have ownership stake in this company and are
not listed on the Quarterly State Tax Withholding report, payroll, or have not yet taken a draw
from this company due to the start date of the business:
1. I attest that the following is true:
a. I am a shareholder, member, officer, or have an ownership stake in the above-
named company.
b. I am actively at work at this company working an average of 30 hours per week
over the course of a month on a permanent and full-time basis.
c. I do not derive substantial earned income from any other employer and am not
eligible for other employer-sponsored coverage.
2. I will provide additional ownership/business validation documents, including the
appropriate IRS forms, as requested.
I understand that this information will be subject to recertification (audit) at renewal and
agree to provide Blue Shield of California, or its affiliates, with any and all information
and documentation necessary to prove the above statements. I also understand that any
misrepresentation by me of my true circumstances may result in termination of group health
coverage from Blue Shield of California, or its affiliates, Small Business health plan for myself,
my enrolled dependents, and/or this company.
Owner Signature
Date
Owner name (please print)
blueshieldca.com
Blue Shield of California is an independent member of the Blue Shield Association A49675 -OWNER-FF (3/20)
