Blue Shield of California

enrollment kit - blue shield of ca (Standalone dental, vision & life)

This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.

Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval.  The following list outlines Blue Shield’s Dental case submission requirements​​​.
  • Completed and signed Master Group Application
    • Master Group Application
      • Section 5 (Standard Industry Classification Code) must be completed for all lines of business. Please ensure that an up-to-date, accurate SIC is captured for all new business case submissions.
  • Employee Application
  • Completed Refusal of Personal Coverage Form​, which can be found on the last page of the Employee Application​​​, ​for each employee not electing coverage​.
    • Required only for groups with one enrolled employee.
  • First months premium
    • Employer Check for the first month’s premium payable to “Blue Shield” or
    • ​Small Group Initial Payment Form
  • Broker Licensing: Producer Agreement - Effective 3/1/2021
​After approval, prior carrier termination letter must be submitted by the employer or broker.​
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For other useful and older documents, please refer to the Forms database.
  • Small Group Initial Payment Form
    • Blue Shield of California

    • form # N/A

    • Effective date: 10.01.2019

  • New Group Submission Checklist - Specialty Benefits
    • Blue Shield of California

    • form # N/A

    • Effective date: 10.01.2019

  • Master Group Application
    • Blue Shield of California

    • form # N/A

    • Effective date: 10.01.2021

  • Medical / Dental / Vision / Life Enrollment Application And Refusal Of Personal Coverage Form
    • Blue Shield of California

    • form # N/A

    • Effective date: 04.01.2021

  • Medical / Dental / Vision / Life Enrollment Application And Refusal Of Personal Coverage Form
    • Blue Shield of California

    • form # N/A

    • Effective date: 07.01.2021

  • Master Group Application
    • Blue Shield of California

    • form # N/A

    • Effective date: 07.01.2021

  • 2021 Producer Agreement
    • Blue Shield of California

    • form # N/A

    • Effective date: 03.01.2021