Applications and Forms

Resources for Participating Employers

2018 Employee application (English)

2017 Employee application (English and Spanish)

2018 Employer application (English)

2017 Employer application (English and Spanish)

Information Update Forms

Employers

2017 Employer form (English)

2018 Employer form (English)


2017 Employer form (Spanish)

2018 Employer form (Spanish)


Employees

2017 Employee form (English)

2018 Employee form (English)


2017 Employee form (Spanish)

2018 Employee form (Spanish)

COBRA forms (COBRA election form, COBRA cancellation form, sample COBRA termination notice and COBRA rights document)

Small Business appeal form

Small Business complaint form

Agent Forms

Agent Transfer Book of Business Form

Agent of Record Transmittal Form

Agent of Record Policy CCSB

Covered California Storefront Program

The Covered California Storefront Program was designed to increase the visibility of free, local and confidential in-person enrollment assistance for consumers. Certified Insurance Agents can connect to the Covered California brand by electing to open a Storefront in their community. Participation in the program is free.

Consumers looking for local, in-person assistance with their application can use the Storefront Finder Tool to search for Storefronts by zip code, days/hours of operation, and languages spoken.

Watch our consumer facing video in English and Spanish and review our User Guide to learn how consumers connect to Covered California Storefronts.

What Are Storefronts? YouTube Video Storefront Finder User Guide

Review our eligibility and signage requirements and to apply to become a Storefront here>>

Covered California Events

Events provide opportunities for consumers to get free assistance from certified enrollers.

Submit new Events here>>

View approved Events here>>