CaliforniaChoice Forms
	CaliforniaChoice - Checklist New Group Sumbission Checklist, 1 Page (Rev. 8-2011)
	CaliforniaChoice Application EE For employees to enroll in the CaliforniaChoice program , 6 Pages (Rev. 10/2011)
	CaliforniaChoice Application Master Group To be completed by the Employer and Broker at initial enrollment., 4 Pages (Rev. 10-2011)
	CaliforniaChoice Employee Change Request Form Used to update personal information or to add/cancel coverage., 3 Pages (Rev. 8-2011)
	CaliforniaChoice Employer Administrative Guide To assist Employers with the healthcare administration of new hires, terminations, benefit and policy changes, etc., 42 Pages (Rev. 10-2011)
	CaliforniaChoice Employer Change Request Form (2-50) Employer contribution, eligibility, or plan changes, 2 Pages (Rev. 10/2011)
	CaliforniaChoice Health Questionnaire Employee For groups of 2-14 medically enrolling employees. , 2 Pages (Rev. 9/10)
	CaliforniaChoice Medical Claim Form - Anthem Blue Cross Anthem Blue Cross Medical Claim Form, 2 Pages (Rev. 2-08)
	CaliforniaChoice Medical Claim Form - Blue Shield of California Blue Shield of California Medical Claim Form, 1 Page (Rev. 8-02)
	CaliforniaChoice Medical Claim Form - Kaiser Permanente To request Reimbursement for emergency services received at a non-Kaiser facility, 3 Pages (Rev. 04-04)
	CaliforniaChoice Medical Claim Form -HealthNet This form may be used for Health Net and Health Net Life Insurance Company products or products offered by your employer group., 2 Pages (Rev. 11-02)
	CaliforniaChoice Owner-Partner Statement To be complete by owners/partners not listed on the De6 or listed with a part-time salary., 1 Page (Rev. 12/2011)
	CaliforniaChoice Renewal Change Request Form For employees to update information and change benefits and/or plan designs during Renewal Only., 4 Pages (Rev. 10-2011)
	CaliforniaChoice Termination Form Employee Complete this form when there is a termination of employment, reduction of hours or loss of life., 1 Page (Rev. 2-10)
	Language Assistance Preference Request Form Members use to request Language Assistance Services Program, allowing interpretation of services and documents into certain languages. , 2 Pages (Rev. 3/10)

CaliforniaChoice Plan Benefit Summaries
	CaliforniaChoice Consumer Direct Plans Benefit Summary Summary showing the Consumer Direct plans, 2 Pages (Rev. 10-2011)
	CaliforniaChoice HMO Benefit Summary Summary showing the HMO benefit, 8 Pages (Rev. 10-2011)
	CaliforniaChoice PPO & HMO Combo Benefit Summaries 12 Pages (Rev. 10/2011)
	CaliforniaChoice PPO Benefit Summary Summary showing the PPO benefit, 4 Pages (Rev. 10-2011)
	Health Plan & Formulary Comparison Guide A Simple Resource to Help You Understand Your Benefits, 24 Pages (Rev. 11-2011)

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For additional information, please contact Claremont at 800.696.4543 or info@claremontcompanies.com