Get Ca C12914 2018

The CA C12914 form, also known as the Small Business Employee Enrollment Form, is essential for enrolling employees in health, dental, vision, and life insurance plans offered by Blue Shield of California. This guide provides clear, step-by-step instructions to help users complete the form accurately.

Follow the steps to complete your CA C12914 enrollment form online.

1. To obtain the CA C12914 form, click the ‘Get Form’ button to access it in your online editor.
2. Begin by filling in your subscriber information, including last name, first name, middle initial, and Social Security number. Ensure that every field is complete to avoid processing delays.
3. Indicate the reason for your application by selecting the appropriate checkbox. Options include new group enrollment, new hire/rehire, open enrollment, COBRA, new spouse/dependent, or other qualifying events.
4. In Section 1a, select one health plan from the list provided based on your employer's package. Review the options for HSA-compatible plans, Tandem PPO plans, Access+ HMO plans, and others.
5. Proceed to Section 1b to select any specialty benefits, including dental, vision, and life insurance plans. Complete the attached Specialty Benefits Employee Benefit Selection Form if required.
6. For Section 2, provide additional subscriber information, including mailing address, work phone number, email address, date of birth, and employment status. Be sure to choose a preferred contact method.
7. If applicable, complete Section 3 by selecting your primary care physician and dental HMO provider if you opted for an HMO plan. This step is not necessary for PPO plan enrollees.
8. In Section 4, enter information about any dependents you wish to enroll, ensuring each dependent's details are clearly filled in, including their names and Social Security numbers.
9. If applicable, fill in Section 5 regarding other health plan information and Section 6 for Medicare information if relevant for yourself or your dependents.
10. Complete Section 7 only if you are enrolling for COBRA or Cal-COBRA continuation coverage. Ensure all qualifying details are clearly provided.
11. In Section 8, read through the disclosure of personal and health information, acknowledging your agreement with a signature and date.
12. Finally, save changes, and check to download, print, or share your completed form as needed.

Start completing your CA C12914 form online today!