Get Blue Shield Of California Employer Notification Of Qualifying Event ...

Filling out the Blue Shield Of California Employer Notification Of Qualifying Event form accurately is essential for ensuring eligible employees receive continuation coverage. This guide provides step-by-step instructions to assist employers in completing the form online.

Follow the steps to effectively complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the employer/company name in the designated field. Ensure that the information is accurate and corresponds to the entity completing the form.
3. Enter the group number associated with your Blue Shield plan. This helps to identify the specific coverage plan for your employees.
4. Provide the employer's phone number and fax number. This information is important for communication regarding the submitted form.
5. Fill in the employee’s name who is experiencing the qualifying event. Be precise in spelling to ensure proper identification.
6. If there is a qualified beneficiary other than the employee, enter their name in the respective field.
7. Input the date of birth for both the employee and any dependent beneficiaries in the designated fields.
8. Specify the employee's Blue Shield ID or Social Security number to verify coverage eligibility.
9. Select the appropriate option if the coverage is solely for a dependent or spouse by marking the checkbox next to 'Dependent child' or 'Spouse/domestic partner.'
10. Provide the address for the employee, ensuring it is current to prevent issues with communication.
11. Indicate the qualifying event by checking the appropriate box. Events include termination, resignation, disqualification of a dependent child, divorce, legal separation, entitlement to Medicare benefits, death of the covered employee, or termination of a domestic partnership.
12. In the respective fields, enter the required dates for the qualifying events to specify when they occurred.
13. Complete the signature section by having the group administrator or producer of record sign where indicated. Print their name and enter the date of signing.
14. If applicable, provide the broker tax ID in the designated section.
15. After completing all sections of the form, review the information for accuracy, then save changes, download, print, or share the completed form as needed.

Complete your documents online today to ensure timely processing of your qualifying events.