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

2022 Employee Application

2022 Employer Application

2021 Employee Application

2021 Employee Application (Spanish)

2021 Employer Application

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 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.

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. For employers who have not yet renewed for the 2022 plan year, please use the 2021 Employer Change Form.

2022 Employer Change Form (English)

2021 Employer Change Form (English)

Employee Change Forms

Use the Employee Change Form to add new employees, make changes due to a qualifying event, or open enrollment. 

2022 Employee Change Form (English)

2022 Employee Change Form (Spanish)

2021 Employee Change Form (English)

2021 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

Quick Reference Documents

New Business Documentation

Offering Infertility Coverage

Employer User Guide