Blue Shield of California Forms:

The following documents are in Portable Document Format (PDF). You will need Adobe Acrobat Reader to view these forms. If you do not have Acrobat Reader, click the Adobe logo at right to download the FREE program.

Application Forms (English):

Employer Application

Employee Application (for companies with 2-50 employees)

Employee Application (for companies with 51-299 employees)

Employee Application (for companies with 300+ employees)

Statement of Domestic Partnership

La Aplicación Forma (Español):

Solicitud del Empleado (cartera de planes para 2-50 empleados)

Solicitud del Empleado (cartera de planes para 51-299 empleados)

Solicitud del Empleado (cartera de planes para 300+ empleados)

Cal-COBRA Forms:

Cal-COBRA Take-Over Form

Employer Notification of Qualifying Event Under Cal-COBRA (SB 719)

Claim Forms:

Subscriber's Statement of Claim

International Claim Form

Pharmacy Program Direct Reimbursement Claim Form

Express Script Brochure

Eligibility Change Forms:

Subscriber Change Request Form / Solicitud de Cambio del Subscriptor (English & Español)

Refusal of Personal Coverage Form

Full Time Student Certification Form

Go to the Blue Shield of California Website


Home \| Contact Us \| News \| About Us \| Services Offered \| Insurance Carriers Frequently Asked Questions \| Existing Clients \| Resources \| Privacy Policy
Copyright ©2003-2011 Aita and Associates Insurance Marketing, Inc - All rights reserved. California License # 0E22529