Enrollment Kit - californiachoice (medical)



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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 CaliforniaChoice’s case submission requirements.

  • Employer Application (includes medical and optional benefits information
     Employer Application - Effective 7/1/2022
  • ​Workers’ Compensation coverage must be in force on or prior to the requested CaliforniaChoice effective date.
  • Group must have a 9-digit Federal Tax ID Number (cannot be SSN#).
  • Quarterly/Annual Wage Report:
    • Required for:
      • Groups with 1-5 medically enrolling employees
      • Virgin groups (regardless of group size)
      • Groups with a lapse of coverage of more than 3 months
  • Must list employee names, social security numbers, wages, and withholdings (no alterations are permitted).
  • Indicate employee status directly on the quarterly/annual wage report (All employees must be accounted for).
​E = Enrolling​W = Waiving​​​P = Part-time​TP = Temporary 
​S = Seasonal​WP = Waiting Period​T = ​Terminated​U = Union
  • W-4 Form is required for new hires not shown on the quarterly/annual wage report.
  • Payroll records required for entire group if more than 50% are not on the quarterly/annual wage report.
  • Payroll may be requested for new hires.
  • Owner / Partner Statem​ent - Effective 9/1/2019:
    • Required if owner(s) not shown on the quarterly/annual wage report with a full-time salary (current state minimum wage multiplied by number of hours to be considered eligible (20 or 30) then multiplied by 13 weeks).
  • Copy of the most recent prior carrier bill is required (no DE9C) for:
    • Groups with 6+ medically enrolling employees.
    • One run of payroll is required for employees not listed on prior carrier bill.
    • Group with a laps of coverage of 3 months or less.
  • Minimum Premium Deposit Check:
    • Employer may submit a copy of the group’s premium deposit check, payable to CaliforniaChoice at case submission. Original check(s) or completed ACH Payment Form for at least 90% of total premium due must be received by the underwriter prior to case approval.
    • COBRA premium is not required, but if submitted, include a separate check from the employer or COBRA enrollee. WageWorks, a HealthEquity company will bill directly.
  • Initial Payment For​m​ (One-Time ACH) - Effective 4/1/2020
  • Employee Application (and dependent waivers, if dependents not enrolling)​.
Employee waivers require reason for waiving and must be completed in full.​​

-Employee Application - Effective 3/1/2022
  • Disabled Dependent Certification - Effective 1/1/2020
  • Must be completed for dependent child(ren) over the age of 26.​
  • Underwriting Guidelines
    • 1-2 Employees:
      • 100% of all employees. All Groups must include at least one medical enrolled employee who is not a business owner or spouse/domestic partner of business owner.
    • 3-100 Employees:
      • 70% of eligible employees enrolling in CaliforniaChoice.
    • ​Employees with other group coverage are not counted towards participation.
    • Group's home office must be located in California (Principal Executive Office).
    • 51+% of eligible employees must reside in California.
  • Case Submission Acknowledgement

    • ​Required when submitting a case to Cal Choice on or after the requested effective date. Disclaimer to members stating that they will not receive ID cards or other materials on time, and that it may take some time to show up in the carrier's system. Not required if case is submitted well ahead of time.

  • Broker Licensing (Current)

​​​After approval, prior carrier termination letter must be submitted by the employer or broker.

For other useful or older documents, please refer to the Forms database.

Important Reminder:  To help your client comply with ACA requirements, provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at the Enrollment Meeting, via email or by posting on an internal company website.  For the most recent information regarding CaliforniaChoice’s SBCs, please go to the SBC Page ​or contact your Word & Brown Representative.