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 Change Form (English)

2018 Employer Change Form (English)

2017 Employer Change Form (Spanish)

2018 Employer Change Form (Spanish)

Employees

2017 Employee Change Form (English)

2018 Employee Change Form (English)

2017 Employee Change Form (Spanish)

2018 Employee Change 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

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 submission deadlines for 2018. While agents should aim to have new enrollment applications into CCSB five business days prior to an effective date for expedited processing, CCSB will accept applications through the last business day of the month.

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 and 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

View Approved Events