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Applications

Document Name	Type
Affidavit of domestic partnership	PDF	Download
California Individual Products Enrollment/Change Application Form	HTML	Download
California Individual Products Enrollment/Change Application Form (Chinese)	HTML	Download
California Individual Products Enrollment/Change Application Form (Korean)	HTML	Download
California Individual Products Enrollment/Change Application Form (Tagalog)	HTML	Download
California Individual Products Enrollment/Change Application Form (Vietnamese)	HTML	Download
California Individual Products Enrollment/Change Application Form(en Español)	HTML	Download
Employee application - Dental and vision coverage for 2-50 members - Small groups	HTML	Download
Employee application - EmployeeElect for 2-50 member small groups	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Chinese)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (en Español)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Korean)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Tagalog)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Vietnamese)	PDF	Download
Exceptions to standard enrollment	PDF	Download

Enrollment

Document Name	Type
Affidavit of domestic partnership	PDF	Download
California Individual Products Enrollment/Change Application Form	HTML	Download
California Individual Products Enrollment/Change Application Form (Chinese)	HTML	Download
California Individual Products Enrollment/Change Application Form (Korean)	HTML	Download
California Individual Products Enrollment/Change Application Form (Tagalog)	HTML	Download
California Individual Products Enrollment/Change Application Form (Vietnamese)	HTML	Download
California Individual Products Enrollment/Change Application Form(en Español)	HTML	Download
Employee application - Dental and vision coverage for 2-50 members - Small groups	HTML	Download
Employee application - EmployeeElect for 2-50 Member Small Groups	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Chinese)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (en Español)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Korean)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Tagalog)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Vietnamese)	PDF	Download
Exceptions to standard enrollment	PDF	Download
Member Authorization Form	PDF	Download

Changes to Benefits

Document Name	Type
Affidavit of domestic partnership	PDF	Download
California Individual Products Enrollment/Change Application Form	HTML	Download
California Individual Products Enrollment/Change Application Form (Chinese)	HTML	Download
California Individual Products Enrollment/Change Application Form (Korean)	HTML	Download
California Individual Products Enrollment/Change Application Form (Tagalog)	HTML	Download
California Individual Products Enrollment/Change Application Form (Vietnamese)	HTML	Download
California Individual Products Enrollment/Change Application Form(en Español)	HTML	Download
Employee application - Dental and vision coverage for 2-50 members - Small groups	HTML	Download
Employee application - EmployeeElect for 2-50 member small groups	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Chinese)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (en Español)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Korean)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Tagalog)	PDF	Download
Employee Application - EmployeeElect for 2-50 Member Small Groups (Vietnamese)	PDF	Download

Claim

Document Name	Type
Dental Claim Form	PDF	Download
Medicare Prescription Drug Claim Form	PDF	Download
Member Claim Form	PDF	Download

HIPAA

Document Name	Type
HIPAA Authorization Form & Instructions - English	PDF	Download
HIPPA Authorization Form & Instructions - Spanish	PDF	Download

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