Complete fillable PDFs online and then print, sign and submit them to Blue Shield. You will need Adobe Reader to complete the fillable form. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version. We recommend using our online version where it is available.
Small Businesses (1-100)| Form | Purpose | Download/ complete online |
|---|---|---|
| Master Group Application (C15385) | This application includes a checklist of all the information and forms your broker will need in order to successfully submit your application. | 2024 Application Download PDF (English) 1 (PDF, 648 KB) Download PDF (Spanish) 1 (PDF, 643 KB) |
| Employee Application (C12914) | Employees should complete this application to enroll in a group medical plan, group vision plan, or group term life policy. Log in to Employer Connection to enroll a new or existing employee. | 2024 Application Download PDF (English) 1 (PDF, 1.5 MB) Download PDF (Spanish) 1 (PDF, 1.5 MB) |
| Disability Addendum (C11248) | This form should accompany the new group application. | Download PDF (PDF, 431 KB) |
| HIPAA Release Form (A46163) | This is an authorization for the release of personal and health information. | Download PDF (PDF, 127 KB) |
| Medicare Advantage Prescription Drug Plans Enrollment Form (MG00001) | This form is for Medicare-eligible retirees who want to enroll in Blue Shield 65 Plus SM , a group Medicare Advantage Prescription Drug plan. | Download PDF (PDF, 117 KB) |
| Medicare Prescription Drug Plan Enrollment Form (PDP00045) | This form is for retirees who want to enroll in Blue Shield of California Medicare Rx Plan (PDP), an Enhanced Group Prescription Drug Benefit plan. | Download PDF (PDF, 118 KB) |
| Form | Purpose | Download/ complete online |
|---|---|---|
| Master Group Application (C14939) | This application includes a checklist of all the information and forms your broker will need in order to successfully submit your application. | 2025 Application Download PDF (English) (PDF, 1.1 MB) Download PDF (Spanish) (PDF, 9.7 MB) Download PDF (Chinese) (PDF, 7.5 MB) Download PDF (Vietnamese) (PDF, 11.6 MB) Download PDF (Persian) (PDF, 5.7 MB) 2024 Application Download PDF (English) (PDF, 1.4 MB) Download PDF (Spanish) (PDF, 1.9 MB) Download PDF (Chinese) (PDF, 3 MB) Download PDF (Vietnamese) (PDF, 2.7 MB) Download PDF (Persian) (PDF, 3.5 MB) |
| Employee Application (C15390) | Employees should complete this form to enroll in a group medical plan, group vision plan or group term life policy. Log in to Employer Connection to enroll a new or existing employee | Log in to complete the application online |
| Employee Application Medical only (C15390-H) | Employees should complete this form to enroll in a group medical plan. For employee enrollments to a new or existing employer group. | 2025 Application Download PDF (English) (PDF, 800 KB) Download PDF (Spanish) (PDF, 541 KB) Download PDF (Chinese) (PDF, 750 KB) Download PDF (Vietnamese) (PDF, 689 KB) Download PDF (Persian) (PDF, 767 KB) 2024 Application Download PDF (English) (PDF, 583 KB) Download PDF (Spanish) (PDF, 608 KB) Download PDF (Chinese) (PDF, 790 KB) Download PDF (Vietnamese) (PDF, 767 KB) Download PDF (Persian) (PDF, 781 KB) |
| Employee Application Life only (C15390-L) | Employees should complete this form to enroll in a group term life policy. For employee enrollments to a new or existing employer group. | 2025 Application Download PDF (English) (PDF, 452 KB) Download PDF (Spanish) (PDF, 468 KB) Download PDF (Chinese) (PDF, 591 KB) Download PDF (Vietnamese) (PDF, 542 KB) Download PDF (Persian) (PDF, 632 KB) 2024 Application Download PDF (English) (PDF, 452 KB) Download PDF (Spanish) (PDF, 460 KB) Download PDF (Chinese) (PDF, 613 KB) Download PDF (Vietnamese) (PDF, 541 KB) Download PDF (Persian) (PDF, 615 KB) |
| Employee Application Medical and life (C15390-HL) | Employees should complete this form to enroll in a group medical plan, group vision plan or group term life policy. For employee enrollments to a new or existing employer group. | 2025 Application Download PDF (English) (PDF, 1.1 MB) Download PDF (Spanish) (PDF, 596 KB) Download PDF (Chinese) (PDF, 757 KB) Download PDF (Vietnamese) (PDF, 688 KB) Download PDF (Persian) (PDF, 785 KB) 2024 Application Download PDF (English) (PDF, 1 MB) Download PDF (Spanish) (PDF, 640 KB) Download PDF (Chinese) (PDF, 821 KB) Download PDF (Vietnamese) (PDF, 725 KB) Download PDF (Persian) (PDF, 806 KB) |
| Medicare Advantage Prescription Drug Plans Enrollment Form (MG00001) | This form is for Medicare-eligible retirees who want to enroll in Blue Shield 65 Plus SM , a group Medicare Advantage Prescription Drug plan. | Download PDF (PDF, 117 KB) |
| Medicare Prescription Drug Plan Enrollment Form (PDP00045) | This form is for retirees who want to enroll in Blue Shield of California Medicare Rx Plan (PDP), an Enhanced Group Prescription Drug Benefit plan. | Download PDF (PDF, 118 KB) |
| Disability Addendum (C11248) | This form should accompany the new group application | Download PDF (PDF, 431 KB) |
| HIPAA Release Form (A46163) | This is an authorization for the release of personal and health information. | Download PDF (PDF, 127 KB) |
| Form | Purpose | Download/ complete online |
|---|---|---|
| COBRA Application (C11825-RTM) | If you are self administering or have a third party federal COBRA administrator and you have a qualified beneficiary electing to participate in COBRA, they must complete this application. Log in to Employer Connection to enroll a new or existing employee | Log in to complete the application online |
1 Complete fillable PDFs online and then print, sign and submit them to Blue Shield. You will need Adobe Reader to complete the fillable form. If you do not have Adobe Reader or are not able to access these fillable features, download the latest version. We recommend using our online version where it is available.
W-9s and other IRS forms Blue Shield of California plans: Download W-9 (PDF, 548 KB) Blue Shield of California Life & Health Insurance Company plans: Download W-9 (PDF, 544 KB) Not sure which form to use? Give us a call at (800) 325-5166. We update these forms often, but still advise that you check the IRS website to make sure you have the most recent W-9s. You can also find the tax forms you need.