How to Apply

What You Will Need to Apply

To apply, employers will need:

  • Their employer name, as reported to the California Employment Development Department.
  • Their federal Employer Identification Number (FEIN) and state Employer Identification Number (SEIN).
  • A copy of their local business license.
  • A DE-9C reconciled by the employer.
  • The total number of employees.
  • The total number of full-time employees.
  • The total number of part-time employees working 20 to 29 hours per week (if offering part-time employees coverage).
  • Their employee roster, including addresses, hire dates, dates of birth and Social Security numbers or tax identification numbers.
  • Dependent information (if offering dependents coverage), including the dependents’ dates of birth to determine their age.

Applications and Forms


Step-by-step instructions are included with each PDF application.

Mail your completed application, including all employee applications and other required documents, to:

Covered California for Small Business
P.O. Box 7010
Newport Beach, CA 92658

Or, fax it to: (949) 809-3264

Need help?

If you have questions about the application or need help completing it, contact Covered California at (844) 332-8384 or contact your Certified Insurance Agent.


Get Important News and Updates

Sign up for email updates to get deadline reminders and other important information.