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CC 51+ Change Request Form
For employees to update personal information or to add/cancel coverage. Not for plan or provider changes, 2 Pages (Rev. 10/08)
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CC 51+ COBRA – Your Legal Responsibility
Use to provide info for current COBRA/Cal-COBRA qualified employees, 1 Page (Rev. 10/04)
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CC 51+ COBRA Enrollment Application
List COBRA employee or dependent enrollee & identify qualifying COBRA event, 2 Pages (Rev. 04/09)
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CC 51+ Disabled Dependent Certification
To be completed by attending physician for disabled dependents age 19+, 1 Page (Rev. 09/08)
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CC 51+ Domestic Partner Affidavit
For the employee to add a domestic partner to the coverage, 1 Page (Rev. 2/08)
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CC 51+ Employee Health Questionnaire
Required for all enrolling employees, 2 Pages (Rev. 12/07)
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CC 51+ Employee Termination Notification Form.
For termination of employment, reduction of hours, loss of life, 1 Page (Rev. 4/07)
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CC 51+ Master Group Application
Required to enroll all new groups, 4 Pages (Rev. 03/10)
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CC 51+ Open Enrollment Change Request Form - Employer
Employers use for plan changes; employee and dependent changes. Not for provider changes., 2 Pages (Rev. 12-09)
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CC 51+ Owner/Partner Statement
Required if owner(s) are not shown on the DE-6 with a full-time salary, 1 Page (Rev. 10/06)
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CC 51+ Privacy Statement
Not a form. Updated privacy policy only., 1 Page (Rev. 07/09)
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CC 51+ Renewal - Change Request Form
Employee to complete at the time of renewal. , 2 Pages (Rev. 02-10)
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CC 51+ Student Verification Form
Submit for dependent full time students enrolled in a medical PPO or Dental PPO/EPO only, 1 Page (Rev. 06-10)
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CC Addendum to Broker Business Agreement
ADDENDUM TO THE BROKER BUSINESS ASSOCIATE AGREEMENT, 1 Page (Rev. 02/10)
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CC Agent Agreement
Required with first CaliforniaChoice group submitted, 2 Pages (Rev. 04/10)
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CC AIG Dental Plans Licensing Form
Required for brokers submitting first case, if not already licensed with CaliforniaChoice, 2 Pages (Rev. 9/02)
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CC Broker Licensing Form
Required with first CaliforniaChoice group submitted, 2 Pages (Rev. 08/09)
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CC Broker Privacy Agreement
This Agreement is drafted for the express purpose of complying with the privacy requirements of the California Insurance Information and Privacy Protection Act (CIC 791 et seq.,“IIPPA”), the Gramm-Leach-Bliley Act (15 U.S.C. §§ 1501 et seq., the “GLBA”) and regulations adopted by the California Department of Insurance to implement IIPPA and the GLBA (10 C.C.R. §§2689.1 et seq., the “IIPPA Privacy Regulations”), the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and regulations
adopted by the U.S. Department of Health and Human Services to implement HIPAA (45 CFR Parts 160-64, the “HIPAA Privacy Regulations”) to ensure the integrity
and confidentiality of individually identifiable personal and health information that Broker may collect, create for or receive from the Company (collectively, the
“Privacy Rule”). Additional terms and conditions in accordance with local privacy ordinances shall be set forth in an Addendum. The term “Privacy Rule” also
includes local privacy ordinances., 4 Pages (Rev. 03/10)
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CC Commission Direct Deposit Authorization Form
For brokers to authorize direct deposit of commission payments, 1 Page (Rev. 09/09)
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For additional information, please contact Claremont at 800.696.4543
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