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

Eligibility and Enrollment Agent Guide

2020 Employee Application (for effective dates Jan. 1 to March 1, 2020)

2020 Employer Application

2019 Employer Application

2019 Employee Application (for effective dates Jan. 1 to June 1, 2019)

2019 Employee Application (for effective dates June 1 to Sept. 30, 2019)

2019 Employee Application (for effective dates Oct. 1 to Dec. 1, 2019)

Submission Deadlines and Late Application Policy

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 2019 and its submission deadlines for 2020.

Existing CCSB Customers

Employer Guide

Please refer to our Employer Guide for information on managing your company’s health and dental plans.

ccsb employer guide thumbnail

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 2019 plan year, please use the 2018 Employer Change Form.

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. 

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

2019 Employee Change Form (English) for effective dates Jan. 1 to June 1, 2019

2019 Employee Change Form (English) for effective dates June 1 to Sept. 30, 2019

2019 Employee Change Form (Spanish) for effective dates Jan. 1 to June 1, 2019

2019 Employee Change Form (Spanish) for effective dates June 1 to Sept. 30, 2019

2018 Employee Change Form (English)

2018 Employee Change Form (Spanish)

Other Forms and Documents

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

Small Business Appeal Form

Small Business Complaint Form

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.