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Employers and employees can rely on us to help them navigate the maze of benefit plans, services, and regulations

Aita & Associates
Insurance Marketing, Inc.
7005 Hazel Cotter Court #G3
Sebastopol, CA 95472

Tel:  707-829-8606
  888-829-8606
Fax:  707-829-8924

CA License #0649963

Email Us


Cal Choice Forms

General Forms - for member enrollment, eligibility and change requests.

BENEFIT-SUMMARY.pdf
Simple matrix outlining basic HMO and PPO benefits

BLUE-SHIELD-PRESCRIPTION-CLAIM-FORM.pdf

CHANGE-REQUEST-EMPLOYEE.pdf
Used to update personal information or to add/cancel coverage. (not for plan or provider changes)

CHANGE-REQUEST-EMPLOYEE-(Spanish).pdf
Used to update personal information or to add/cancel coverage. (not for HCSP, doctor or dentist change.

DENTAL-4000-5000-CLAIM-FORM.pdf
Security Dental Claim Form

DENTAL-BUY-UP-APPLICATION-INFORCE-GROUP.pdf
For an in-force group to enroll in dental plans 1000, 3000, 3500, 4000 or 5000 after initial enrollment.

DENTAL-CLAIM-FORM-(AIG).pdf
Claim form for dental plans EPO 3500, PPO 4000 and PPO 5000

DISABLED-DEPENDENT-CERTIFICATION.pdf
To be completed by the employee and dependent's physican when enrolling a disabled dependent child ages 19+.

DOMESTIC-PARTNER-AFFIDAVIT.pdf
Domestic Partner Coverage must be offered by Employer before employee can elect. *Only applicable to inforce groups that have not yet renewed in 2005 To be completed by the employee when adding a domestic partner to employee''''s coverage.

DOMESTIC-PARTNER-AFFIDAVIT-(Spanish).pdf
Domestic Partner Coverage must be offered by Employer before employee can elect. *Only applicable to inforce groups that have not yet renewed in 2005 To be completed by the employee when enrolling a domestic partner.

EMPLOYEE-APPLICATION-(1.1.05-and-After).pdf
For groups enrolling or renewing for an effective date of 1/1/05 and after For employees to enroll in the CaliforniaChoice program

EMPLOYEE-APPLICATION-(Prior-to-1.1.05).pdf
For groups enrolling or renewing for an effective date prior to 1/1/05 For employees to enroll in CaliforniaChoice

EMPLOYEE-APPLICATION-(Spanish)-(1.1.05-and-After).pdf
For groups enrolling or renewing for an effective date of 1/1/05 and after Spanish Application for employees to enroll in the CaliforniaChoice program.

EMPLOYEE-APPLICATION-(Spanish)-(Prior-to-1.1.05).pdf
For groups enrolling or renewing for an effective date prior to 1/1/05 Spanish Application for employees to enroll in CaliforniaChoice.

EMPLOYEE-ENROLLMENT-GUIDE-(Spanish)-(1.1.05-and-After).pdf
For groups enrolling or renewing for an effective date of 1/1/05 and after Provides information regarding CaliforniaChoice plans, benefits, employee and dependent eligibility requirements, etc.

EMPLOYER-APPLICATION-(1.1.05-and-After).pdf
For groups enrolling for an effective date of 1/1/05 and after. To be completed by the Employer and Broker at initial enrollment.

FORMULARY-GUIDE-(1.1.04-6.1.04).pdf
For groups that enrolled or renewed for an effective date of 1/1/04 through 6/1/04 Lists the various prescriptions covered by each of the health plans within the CaliforniaChoice program.

FORMULARY-GUIDE-(1.1.05-6.1.05).pdf
For groups enrolling or renewing for an effective date of 1.1.05 through 6.1.05 Lists the various prescriptions covered by each of the health plans within the CaliforniaChoice program.

FORMULARY-GUIDE-(7.1.04-12.1.04).pdf
For groups enrolling or renewing for an effective date of 7.1.04 through 12.1.04 Lists the various prescriptions covered by each of the health plans within the CaliforniaChoice program.

HEALTH-NET-MEDICAL-CLAIM-FORM.pdf

HEALTH-QUESTIONNAIRE.pdf
To be completed by employees in a group with only 2-14 medically enrolled employees.

PRIVACY-STATEMENT.pdf
This statement tells about the information requested from customers and how we safeguard the information and protect privacy rights

SALUD-SALUD-MEXICO-APPLICATION-BROCHURE-(English).pdf
For employees who reside in Los Angeles or North Orange counties and select zips of Imperial and San Diego counties enrolling for Health Net Salud or Salud Mexico Plan.

SALUD-SALUD-MEXICO-APPLICATION-BROCHURE-(Spanish).pdf
For employees who reside in Los Angeles or North Orange counties and select zips of Imperial and San Diego counties enrolling for Health Net Salud or Salud Mexico Plan.

STUDENT-VERIFICATION.pdf
To be completed by employees enrolling dependents ages 19-24 in a PPO plan.
Brochures and Guides - for information you need on CaliforniaChoice products and eligibility.

CHIROPLUS-BENEFIT-SHEET.pdf
For all groups, new and inforce, starting 4/1/2005 A one-page table of benefits for the Chiro Only and the Chiro an Acupuncture plan.

CHOICE-BROCHURE.pdf
Sales brochure highlighting CaliforniaChoice benefits and services

CONSUMER-GUIDE-(1.1.04-6.1.04).pdf
For groups that enrolled or renewed for an effective date between 1/1/04 through 6/1/04 Information to assist employees with their health plan choices.

CONSUMER-GUIDE-(7.1.04-and-12.1.04).pdf
For groups that enrolled or renewed for for an effective date of 7/1/04 through 12/1/04. Information to assist employees with their health plan choices.

DENTAL-100-BROCHURE-FDH.pdf
First Dental Health Access 100 program summary of benefits and discounts.

DENTAL-100-COPAY-GUIDE.pdf
FDH dental services copay guide by region.

DENTAL-100-PROVIDER-LIST-FDH.pdf
A list of California dentists and dental groups participating in the First Dental Health 100 Access program.

DENTAL-3500-PROVIDER-LIST-FDH.pdf
A list of dentists and dental groups participating in the First Dental Health EPO 3500 program.

DENTAL-4000_5000-PROVIDER-LIST-FDH.pdf
A list of California dentists and dental groups partipating in the First Dental Health PPO Access program.

DENTAL-EMPLOYEE-BENEFITS-GUIDE.pdf
For groups that enrolled or renewed for an effective date of 1/1/05 or after Information on all optional dental plans available through CaliforniaChoice.

DENTAL-PROVIDER-DIRECTORY-FDH-CA-(EPO-PPO-Plans).pdf
A statewide provider directory for the First Dental Health EPO and PPO dental plans.

EMPLOYEE-ENROLLMENT-GUIDE-(1.1.04-6.1.04).pdf
For groups that enrolled or renewed for an effective date of 1/1/04 through 6/1/04. Provides information regarding CaliforniaChoice plans, benefits, employee and dependent eligibility requirements, etc.

EMPLOYEE-ENROLLMENT-GUIDE-(1.1.05-and-After).pdf
For groups enrolling or renewing for an effective date of 1/1/05 and after Provides information regarding CaliforniaChoice plans, benefits, employee and dependent eligibility requirements, etc.

EMPLOYEE-ENROLLMENT-GUIDE-(7.1.04-12.1.04).pdf
For groups enrolling or renewing for an effective date of 7/1/04 through 12/1/04. Provides information regarding CaliforniaChoice plans, benefits, employee and dependent eligibility requirements, etc.

EMPLOYEE-ENROLLMENT-GUIDE-(Spanish)-(1.1.05-and-After).pdf
For groups enrolling or renewing for an effective date of 1/1/05 and after Provides information regarding CaliforniaChoice plans, benefits, employee and dependent eligibility requirements, etc.

FORMULARY-GUIDE-(1.1.04-6.1.04).pdf
For groups that enrolled or renewed for an effective date of 1/1/04 through 6/1/04 Lists the various prescriptions covered by each of the health plans within the CaliforniaChoice program.

FORMULARY-GUIDE-(1.1.05-6.1.05).pdf
For groups enrolling or renewing for an effective date of 1.1.05 through 6.1.05 Lists the various prescriptions covered by each of the health plans within the CaliforniaChoice program.

HEALTH-PLAN-COMPARISON-GUIDE-(formerly-Consumer-Guide)-(1.1.05-6.1.05).pdf
For groups enrolling or renewing for an effective date of 1.1.05 through 6.1.05. Information to assist employees with their health plan choices.

HEALTHNET-OPEN-ELECT-ACCESS-BROCHURE.pdf
Questions and answers for HealthNet's Open Elect Access plan.

HMO-BENEFIT-GUIDE-EMPLOYEE-(Spanish).pdf
Provides information about HMO plans, benefits, employee and dependent eligibility requirements.

OPTIONAL-BENEFITS-GUIDE-EMPLOYER.pdf
For groups with an effective or renewal date of 1/1/05 and after. (New chiro benefits effective 4/1/05) Information on optional benefits including Life, Dental, Chiro, Vision and Section 125 premium only plan.

OPTIONAL-BENEFITS-GUIDE-EMPLOYER2.pdf
For groups with an effective or renewal date of 1/1/05 and after. Information on optional benefits including Life, Dental, Chiro, Vision and Section 125 premium only plan offered through

RATE-GUIDE-HMO-(1.1.04-6.1.04).pdf
Employee and dependent HMO rates for groups with an effective date or renewal date of 1/1/04 through 6/1/04.

RATE-GUIDE-HMO-(1.1.05-6.30.05).pdf
Employee and dependent HMO rates for groups with an effective or renewal date of 1/1/05 through 6/1/05

RATE-GUIDE-PPO-(1.1.04-6.1.04).pdf
Employee and dependent PPO rates for groups with an effective or renewal date of 1/1/04 through 6/1/04.

RATE-GUIDE-PPO-(1.1.05-6.30.05).pdf
Employee and dependent PPO rates for groups with an effective date or renewal date of 1/1/05 through 6/1/05.

VISION-BROCHURE.pdf
Information about Voluntary Vision and LASIK programs.

VISION-BROCHURE-(Spanish).pdf
Information about Voluntary Vision and LASIK programs.


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.

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Nancy J. Aita, CEBS, CA License # 0649963
Aita & Associates Insurance Marketing, Inc.
7005 Hazel Cotter Court #G3
Sebastopol, CA 95472
Tel: 707-829-8606
Fax: 707-829-8924
Toll-free: 888-829-8606

Email Us

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