Applications and Forms
Welcome to Covered California for Small Business! The resources below are designed to assist your small business manage its responsibilities as a plan sponsor. Step-by-step instructions are included with each resource, but feel free to contact us should you need further assistance. We’re here to help!
Become a CCSB Customer
2020 Employee Application (for effective dates Jan. 1 to March 1, 2020)
2020 Employee Application (for effective dates April 1 to June 1, 2020)
2020 Employee Application (for effective dates July 1 to Sept. 1)
2020 Employee Application (for effective dates Oct. 1 to Dec. 1, 2020)
2021 Employee Application (for effective dates Jan. 1 to March 1, 2021)
2020 Employee Application (for effective dates Oct. 1 to Dec. 1, 2020
Submission Deadlines and Late Application Policy
Submission Deadlines for 2022
Covered California for Small Business (CCSB) will accept new-business submissions through the first five business days of the month for same-month coverage, provided a New Business Late-Submission Acknowledgement Form is signed and submitted with the enrollment application. Be advised that the New Business Late-Submission Acknowledgement Form is an optional form. If the group does not agree to the submission acknowledgement, the effective date will be the first of the month following the requested effective date. Covered California for Small Business has updated its application and submission deadlines for 2022.
Existing CCSB Customers
Employer Guide
Please refer to our Employer Guide for information on managing your company’s health and dental plans.
Employer Change Forms
Use the Employer Change Form to make changes in your group’s reference plan, metal tier levels, and contribution levels or to change the address or ownership of your small business. For employers that have not yet renewed for the 2021 plan year, please use the 2020 Employer Change Form.
2021 Employer Change Form (English)
2021 Employer Change Form (Spanish)
2020 Employer Change Form (English)
2020 Employer Change Form (Spanish)
2019 Employer Change Form (English)
2019 Employer Change Form (Spanish)
Employee Change Forms
Use the Employee Change Form to add new employees, make changes due to a qualifying event, or open enrollment.
2021 Employee Change Form (English) for effective dates Jan. 1 to March 1, 2021
2021 Employee Change Form (Spanish) for effective dates Jan. 1 to March 1, 2021
2020 Employee Change Form (English) for effective dates Jan. 1 to March 1, 2020
2020 Employee Change Form (Spanish) for effective dates Jan. 1 to March 1, 2020
2020 Employee Change Form (English) for effective dates April 1 to June 1, 2020
2020 Employee Change Form (Spanish) for effective dates April 1 to June 1, 2020
2020 Employee Change Form (English) for effective dates July 1 to September 1, 2020
2020 Employee Change Form (Spanish) for effective dates July 1 to September 1, 2020
2020 Employee Change Form (English) for effective dates Oct. 1 to Dec. 1, 2020
2020 Employee Change Form (Spanish) for effective dates Oct. 1 to Dec. 1, 2020
2020 Employee Change Form (English) for effective dates Oct. 1 to Dec. 1, 2020
2020 Employee Change Form (Spanish) for effective dates Oct. 1 to Dec. 1, 2020
2019 Employee Change Form (English) for effective dates Jan. 1 to June 1, 2019
2019 Employee Change Form (Spanish) for effective dates Jan. 1 to June 1, 2019
2019 Employee Change Form (English) for effective dates June 1 to Sept. 1, 2019
2019 Employee Change Form (Spanish) for effective dates June 1 to Sept. 1, 2019
2019 Employee Change Form (English) for effective dates Oct. 1 to Dec. 1, 2019
2019 Employee Change Form (Spanish) for effective dates Oct. 1 to Dec. 1, 2019
Other Forms and Documents
COBRA forms (COBRA election form, COBRA cancellation form, sample COBRA termination notice and COBRA rights document)
Book of Business Transfer Form
To update the Agent/Agency FEIN Tax ID with the same writing agent, please use the Agent/Agency Entity Update Profile Conversion Form.