Get Californiachoice Employer Change Request Form ... - Superagent

The CaliforniaChoice Employer Change Request Form is essential for managing employee benefits and changes within your organization. This guide will provide clear instructions on how to complete the form effectively, ensuring all necessary details are included for a smooth transition.

Follow the steps to complete your form.

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred editing tool.
2. In the 'Group Name' field, enter the official name of your organization as registered with CaliforniaChoice.
3. In the 'CaliforniaChoice Group #' section, provide your unique group number assigned by CaliforniaChoice.
4. For Section A, 'Change Address/Phone/Fax', fill in the group’s new billing address, checking the box if it is the same as the street address. Also, update any phone or fax numbers as necessary.
5. In Section B, 'Add/Change Contact', add the primary and additional contacts' details, including title, phone number, and email address. Remove any contacts who are no longer authorized by listing their names and titles.
6. Section C is for 'Add Life Insurance'. Choose whether you want a flat amount or a scheduled amount for life insurance coverage and ensure to list the number of eligible employees.
7. For Section D and subsequent sections about adding benefits, mark the options you seek, ensuring to complete any additional applications required as referenced.
8. Fill out the employer contribution changes in Section J if applicable, choosing either a percentage of cost or fixed dollar amount.
9. In Section K and L, indicate any changes to waiting periods or hours of eligibility for your employees before submitting the form.
10. Finally, sign and print your name in the designated areas to confirm the accuracy of the information provided.
11. After completing the form, save your changes, and choose to download, print, or share it as needed.

Complete your CaliforniaChoice Employer Change Request Form online today to ensure your benefits are up to date.