How to Apply
What You Will Need to Apply
To apply, employers will need:
- Their employer name, as reported to the California Employment Development Department.
- Their federal Employer Identification Number (FEIN) and state Employer Identification Number (SEIN).
- A copy of their local business license.
- A DE-9C reconciled by the employer.
- The total number of employees.
- The total number of full-time employees.
- The total number of part-time employees working 20 to 29 hours per week (if offering part-time employees coverage).
- Their employee roster, including addresses, hire dates, dates of birth and Social Security numbers or tax identification numbers.
- Dependent information (if offering dependents coverage), including the dependents’ dates of birth to determine their age.
Applications and Forms
Step-by-step instructions are included with each PDF application.
Mail your completed application, including all employee applications and other required documents, to:
Covered California for Small Business
P.O. Box 7010
Newport Beach, CA 92658
Or, fax it to: (949) 809-3264Need help?
If you have questions about the application or need help completing it, contact Covered California at (844) 332-8384 or contact your Certified Insurance Agent.