Get Californiachoice Employer Change Request Form (cc 0564)

The CaliforniaChoice Employer Change Request Form (CC 0564) enables administrators to update essential information regarding their group health insurance coverage. This guide provides step-by-step instructions for filling out the form online, ensuring a smooth process for users.

Follow the steps to fill out the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the group name and CaliforniaChoice Group number in the designated fields.
3. In section A, if applicable, check the box indicating that the billing address and street address are the same. If not, fill in the new billing and street address, including city, state, and zip code.
4. In section A, provide any new phone and fax numbers, unless they have not changed.
5. In section B, add or change the contacts by filling out the names, titles, direct lines, and emails of the primary and additional contacts. Ensure you remove any contacts no longer authorized.
6. In section C, if applying for life insurance, select the flat amount for all employees based on the number of eligible employees and follow the guidelines listed.
7. Sections D through J allow you to add various benefits such as chiropractic, dental, and vision. Fill in the necessary checkboxes and additional forms if required.
8. Complete the premium contribution section in section K by selecting your contribution options and entering any relevant percentages or dollar amounts.
9. Adjust hours of eligibility and waiting periods in section M as needed.
10. Sign and date the form at the end, ensuring the signatory is an authorized contact.
11. Once all changes are made, save your changes, and download, print, or share the completed form as required.

Take action now to fill out your CaliforniaChoice Employer Change Request Form online and keep your records updated.