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

2024 Employee Application

2024 Employee Application (Spanish)

Q3-Q4 2023 Employee Application for Effective Dates: 7/1/2023 to 12/1/2023

Q1-Q2 2023 Employee Application for Effective Dates: 1/1/2023 to 6/1/2023

Employer Application

New! Combined Application and Change Form

The new combined employee enrollment and change request form allows for new enrollment requests and changes to existing coverage to be submitted on one simple form! Feel free to contact us should you need further assistance.

Separate employee application and change forms will still be accepted.

Enrollment and Change Request for Employees

Submission Deadlines and Late Application Policy

Submission Deadlines for 2024

Submission Deadlines for 2023

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.

Existing CCSB Customers

Employer Guide 

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

Covered California Small Business Employer Guide PDF

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.

Employer Change Form (English)

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. 

2024 Employee Change Form (English)

2024 Employee Change Form (Spanish)

Q3-Q4 2023 Employee Change Form for Effective Dates: 7/1/2023-12/1/2023 (English)

Q1-Q2 2023 Employee Change Form for Effective Dates: 1/1/2023-6/1/2023 (English)

Q3-Q4 2023 Employee Change Form (Spanish) for Effective Dates: 7/1/2023 to12/1/2023 (Spanish)

Q1-Q2 2023 Employee Change Form (Spanish) for Effective Dates: 1/1/2023 to 6/1/2023 (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

Quick Reference Documents

New Business Documentation

Employer Eligibility and Enrollment System User Guide

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