HSA California Forms
	A Checklist - HSA California New Group Submission Checklist, 1 Page (Rev. 8-2011)
	Application Employee 4 Pages (Rev. 10/2011)
	Application Employer Master Group 4 Pages (Rev. 10/2011)
	Disabled Dependent Certification A dependent child who is incapable of self-support due to a continuously disabling illness or injury may be continued as a family member on the parent's health coverage., 1 Page (Rev. 10/2011)
	Domestic Partnership Affidavit 1 Page (Rev. 08/09)
	Employee Change Request Form For effective dates 1/1/2012 to 6/1/2012 Used to update personal information or to add/cancel coverage due to a qualifying event. , 4 Pages (Rev. 10-2011)
	Employer Administrative HandBook This Employer Administrative Handbook is intended to guide you through different administrative procedures, as well as answer general questions about the HSA California program., 40 Pages (Rev. 10-2011)
	Employer Change Request Form For effective dates 1/1/2012 to 6/1/2012 For the Employer to request Off-Anniversary or Renewal Only changes to the group's policy., 2 Pages (Rev. 10-2011)
	Employer Optional Benefits Guide A guide wich discribes the Optional Benefits offered by HSA CAlifornia, Dental, Life and Section 125 Premium Only Plan (POP), 11 Pages (Rev. 10-2011)
	Group COBRA Billing Contract Complete this Contract if you would like to be billed for COBRA participants., 1 Page (Rev. 10-2011)
	Health Plan and Formulary Comparison Guide Lists the various prescriptions covered by each of the health plans within the HSA California program.Discribes Prescription drug plans benefits. Compares Brand Name to Generic Drugs. , 12 Pages (Rev. 10/2011)
	Language Assistance Preferance Request Program that include interpretation services in many languages and also translations of certain important documents in certain languages, if they are also used by your Health Plan., 2 Pages (Rev. 08/09)
	Owner-Partner Statement Groups with less than 5 employees enrolled must provide proof of eligibility for each owner/officer as requested by HSA California Underwriting., 1 Page (Rev. 11/2011)
	Prior Carrier Cancellation Used to cancel prior carrier participation, 1 Page (Rev. 06/08)
	Self-Funding Declaration 1 Page (Rev. 08/08)

Benefit Summary
	HSA Benefit Summary 2 Pages (Rev. 11-2011)

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