|
AIG Dental Plans Licensing Form
Required for brokers submitting first case, if not already licensed with CaliforniaChoice, 2 Pages (Rev. 9/02)
|
|
|
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. 7/07)
|
|
|
CC 51+ COBRA – Your Legal Responsibility
Use to provide info for current COBRA/Cal-COBRA qualified employees, 1 Page (Rev. 10/04)
|
|
|
CC 51+ COBRA Enrollment Application
List COBRA employee or dependent enrollee & identify qualifying COBRA event, 2 Pages (Rev. 7/07)
|
|
|
CC 51+ Disabled Dependent Certification
To be completed by attending physician for disabled dependents age 19+, 1 Page (Rev. 10/04)
|
|
|
CC 51+ Domestic Partner Affidavit
For the employee to add a domestic partner to the coverage, 1 Page (Rev. 2/08)
|
|
|
CC 51+ Employee Health Questionnaire
Required for all enrolling employees, 2 Pages (Rev. 4/07)
|
|
|
CC 51+ Employee Termination Notification Form.
For termination of employment, reduction of hours, loss of life, 1 Page (Rev. 4/07)
|
|
|
CC 51+ Master Group Application
Required to enroll all new groups, 4 Pages (Rev. 7/07)
|
|
|
CC 51+ Med/Dent/Life/Vis Employee Enrollment Application
To be completed by each enrolling employee. Includes Waiver of Coverage., 3 Pages (Rev. 2/08)
|
|
|
CC 51+ Open Enrollment Change Request Form
Employers use for plan changes; employee and dependent changes. Not for provider changes., 2 Pages (Rev. 8/07)
|
|
|
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)
|
|
|
CC 51+ Student Verification Form
Submit for dependent full time students enrolled in a medical PPO or Dental PPO/EPO only, 1 Page (Rev. 3/07)
|
|
|
CC Agent Agreement
Required with first CaliforniaChoice group submitted, 1 Page (Rev. 3/06)
|
|
|
CC Broker Licensing Form
Required with first CaliforniaChoice group submitted, 2 Pages (Rev. 1/08)
|
|
|
CC Commission Direct Deposit Authorization Form
For brokers to authorize direct deposit of commission payments, 1 Page (Rev. 9/06)
|
|
|
CC Privacy Statement
Not a form. Updated privacy policy only., 1 Page (Rev. 5/07)
|
Be sure you have the latest free version of Acrobat Reader
from Adobe. This program will allow you to store and print the forms from your
hard drive. If you do not have Adobe Acrobat Reader, click
here or on the "Get Acrobat Reader" Image, to download the
software.
For additional information, please contact Claremont at 800.696.4543
or
info@claremontcompanies.com
