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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 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)
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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. 7/07)
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CC 51+ Disabled Dependent Certification To be completed by attending physician for disabled dependents age 19+, 1 Page (Rev. 10/04)
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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. 4/07)
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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. 7/07)
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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)
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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)
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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+ Student Verification Form Submit for dependent full time students enrolled in a medical PPO or Dental PPO/EPO only, 1 Page (Rev. 3/07)
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CC Agent Agreement Required with first CaliforniaChoice group submitted, 1 Page (Rev. 3/06)
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CC Broker Licensing Form Required with first CaliforniaChoice group submitted, 2 Pages (Rev. 1/08)
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CC Commission Direct Deposit Authorization Form For brokers to authorize direct deposit of commission payments, 1 Page (Rev. 9/06)
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CC Privacy Statement Not a form. Updated privacy policy only., 1 Page (Rev. 5/07)
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For additional information, please contact Claremont at 800.696.4543
or
info@claremontcompanies.com