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Forms Finder

Select the size of your group and the carrier you want to work with. Then specify whether it’s new or existing business, then select the product type. You can also search for additional miscellaneous carrier enrollment tools. Please contact sales@dickerson-group.com if you are having trouble finding your desired form.

(Note: Please choose either new or existing business)

SPECIAL NOTE:
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  • New Business Effective Date

  • Existing Business Effective Date

  • Group Size

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Click Here for Additional Carrier Sales Materials

Complete Carrier 2022 Enrollment Kits

See below for complete enrollment kits for each carrier. Please note that the date in parenthesis indicates the effective date of the form.

All forms, even if a few months old, are the most up-to-date.

Aetna Complete Enrollment Kit
Aetna New Business Checklist
Aetna Employer App (2023)
Aetna Employee App (2023)
Aetna ACA Banking Consent
Aetna Proof of Eligibility Form
Aetna Open Enrollment Attestation Form
Aetna Employee Enrollment Change Form (1.1.23) Spanish

Anthem Complete Enrollment Kit
Anthem Combined Medical & Specialty Employer App (1-1-23)
Anthem Combined Medical & Specialty Employee App (1-1-23)
Anthem Combined Medical and Specialty Employee Application (1-1-23) Spanish
Anthem Electronic Funds Transfer (EFT) Authorization Form
Anthem Employee Waiver Form (1-1-23)
Anthem Employee Waiver Form (1-1-23) Spanish
Anthem Eligibility Statement
Anthem Conditions of Enrollment: Start Up Companies, PEO, Spin Off Groups
Anthem Small Group Agent Checklist

Blue Shield Complete Enrollment Kit
Blue Shield New Business Checklist
Blue Shield Employer Application (1-1-23)
Blue Shield Employee Application (1-1-23)
Blue Shield Employee Refusal of Coverage Form (1-1-23)
Blue Shield Employer Application (1-1-23) Spanish version
Blue Shield Employee Application (1-1-23) Spanish version
Blue Shield Initial Payment Form
Blue Shield Owner Eligibility Statement
Blue Shield - Start-up/Spin-off Companies Eligibility Statement

California Choice Complete Enrollment Kit
California Choice New Business Checklist (1-1-23)
California Choice Employer Application (4-1-23 thru 6-30-23)
California Choice Employer Application (1-1-23 to 3-31-23)
California Choice Employee Application (4-1-23 thru 6-30-23)
California Choice Employee Enrollment App (1-1-23)
California Choice Employee Application (Effective 1-1-23) Spanish
California Choice Employee Application (4-1-23 thru 6-30-23) Spanish
California Choice ACH Payment Form
California Choice Owner/Partner Statement
California Choice Case Submission Acknowledgement
California Choice Group Size Attestation
California Choice Confirmation of Eligibility

Choice Builder Complete Enrollment Kit
Choice Builder Case Submission Checklist (7/1/22)
Choice Builder Employer Application (7-1-22)
Choice Builder Employer Application (12-1-2022)
Choice Builder Employee Application (1-1-22)
Choice Builder Employee App (Spanish) (1-1-22)
Choice Builder ACH Payment Form (1-1-22)
Choice Builder Late Submission Acknowledgement Form
Choice Builder Benefit Summaries (1-1-22)
Choice Builder Confirmation of Eligibility

Cigna + Oscar Complete Enrollment Kit
Cigna + Oscar Business Enrollment Form (California 2023)
Cigna + Oscar Employee App / Change Request Form - California 2023
Cigna + Oscar California Employee Waiver Form 2023
Cigna + Oscar ACH Authorization Form 2023
Cigna + Oscar Corporate Officer Proprietor Partner Verification Form 2023

Covered California Complete Enrollment Kit
Covered California New Business Checklist
Covered California Employer Application (1-1-23)
Covered California 2023 Employee Application
Covered California Employee App (Spanish) (2023)
Covered California Late Submission Acknowledgment
Covered California How to Get a Small Business Credit

Health Net Complete Enrollment Kit
Health Net New Business Checklist
Health Net Employer App (1-1-23)
Health Net Employee Enrollment and Change Form (1-1-23)
Health Net Employee Enrollment and Change Form (Spanish) (1-1-23)
Health Net Electronic Check Form (2023)
Health Net Proof of Eligibility Statement For Sole Proprietor, Partner or Corporate Officer (2023)
Health Net Reasons for Employee Enrollment Delays

Kaiser Complete Enrollment Kit
Kaiser New Business Checklist (1-1-22)
Kaiser Employer-Application (1-1-23)
Kaiser Employee App (1-1-23)
Kaiser Employee App (Spanish) (1-1-22)
Kaiser Employee App (Chinese) (1-1-21)
Kaiser Owner/Officer Eligibility Statement (1-1-22)
Kaiser New Employee Eligibility (1-1-22)
Kaiser Electronic Transfer for Initial Payment Form (1-1-22)
Kaiser Employer Declination of Coverage (1-1-22) English
Kaiser Employer Declination of Coverage (1-1-22) Spanish
Kaiser Employer Declination of Coverage (1-1-22) Chinese
Kaiser Employee Declination of Coverage (1-1-22) English
Kaiser Employee Declination of Coverage (1-1-22) Spanish
Kaiser Employee Declination of Coverage (1-1-22) Chinese
Kaiser Payroll Attestation Form (1-1-22)

MediExcel Complete Enrollment Kit
MediExcel Small Group Eligibility Checklist
MediExcel Small Group Employer Application (10-1-2022)
MediExcel Small Group Employer Application (1-1-2022)
MediExcel Large Group Employer Application (10-1-2022)
MediExcel Large Group Employer Application (1-1-2022)
MediExcel Employee App (English) (1-1-22 updated)
MediExcel Employee App (English) (1-1-22)
MediExcel Employee App (Spanish) (1-1-22 updated)
MediExcel Employee App (Spanish) (1-1-22)
MediExcel Declination of Coverage Form (English & Spanish)
MediExcel Affidavit For Enrollment Of Domestic Partner (1-1-22) English
MediExcel Affidavit For Enrollment Of Domestic Partner (1-1-22) Spanish
MediExcel Continuity of Care Form (1-1-22)
MediExcel SENTRI Pass Reimbursement Form
MediExcel Request Form for Reimbursement of Healthcare Services

United Healthcare Complete Enrollment Kit
United Healthcare New Business Checklist
United Healthcare Employer App
United Healthcare Employee App
United Healthcare Scheduled Direct Debit Authorization Form (1-1-22)
United Healthcare Group Acceptance/Change Form Product and Benefit Selection Form (1-1-22)

Benefit Summaries

• Aetna

• Anthem Blue Cross

• Blue Shield

• CaliforniaChoice ® 

• Choice Builder® 

• Health Net

• Kaiser Permanente

• Oscar Health

• SIMNSA

 

Summary of Benefits and Coverage (SBC)

• Aetna

• Anthem Blue Cross

• Blue Shield

• CaliforniaChoice ®

• Health Net

• Kaiser Permanente

• MediExcel

• Oscar Health

Covered California for Small Business

• Blue Shield

• CCHP Health Plan

• Health Net

• Kaiser Permanente

• Sharp

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