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CC 51+ Application Employer
For effective dates 1/1/2012 to 3/1/2012
To be completed by the Employer and Broker at initial enrollment, 4 Pages (Rev. 10/2011)
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CC 51+ Application EmployerApril2012
For effective dates 4/1/2012 to 6/1/2012
To be completed by the Employer and Broker at initial enrollment, 4 Pages (Rev. 12/2011)
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CC 51+ ApplicationEmployee
For effective dates 1/1/2012 to 3/1/2012
For employees to enroll in CaliforniaChoice 51+, 4 Pages (Rev. 10/2011)
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CC 51+ ApplicationEmployeeApril2012
For effective dates 4/1/2012 to 6/1/2012
For employees to enroll in CaliforniaChoice 51+, 4 Pages (Rev. 12/2011)
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CC 51+ COBRA
Use to provide info for current COBRA/Cal-COBRA qualified employees. Your LEGAL Responsibility, 1 Page (Rev. 11/2004)
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CC 51+ COBRA Enrollment Application
List COBRA employee or dependent enrollee & identify qualifying COBRA event, 2 Pages (Rev. 11/2011)
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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+ EmployeeChange Request Form
Used to update personal information or to add/cancel coverage. (not for plan or provider changes), 2 Pages (Rev. 10/2011)
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CC 51+ EmployeeChangeRequestRenewal Form
Used to update personal information or to add/cancel coverage. (not for plan or provider changes), 3 Pages (Rev. 10/2011)
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CC 51+ Employer Change Request Form
For effective dates 1/1/2012 to 3/1/2012
For the Employer to request Off-Anniversary or Renewal Only changes to the group's policy., 2 Pages (Rev. 10/2011)
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CC 51+ Employer Change Request FormApril2012
For effective dates 4/1/2012 to 6/1/2012
For the Employer to request Off-Anniversary or Renewal Only changes to the group's policy, 2 Pages (Rev. 12/2011)
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CC 51+ Health Questionnaire EE
Required for all enrolling employees, 2 Pages (Rev. 1/2011)
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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. 11/2011)
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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+ 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 51+ Termination Notification EE Form
For termination of employment, reduction of hours, loss of life, 1 Page (Rev. 2/2010)
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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
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
or
