Applications and Forms
Welcome to Covered California for Small Business! The resources below are designed to assist your small business manage its responsibilities as a plan sponsor. Step-by-step instructions are included with each resource, but feel free to contact us should you need further assistance. We’re here to help!
Become a CCSB Customer
2024 Employee Application (Spanish)
Employer Application (Spanish)
Q3-Q4 2023 Employee Application for Effective Dates: 7/1/2023 to 12/1/2023
New! Combined Application and Change Form
The new combined employee enrollment and change request form allows for new enrollment requests and changes to existing coverage to be submitted on one simple form! Feel free to contact us should you need further assistance.
Separate employee application and change forms will still be accepted.
2025 Enrollment and Change Request for Employees
2025 Enrollment and Change Request for Employees (Spanish)
2024 Enrollment and Change Request for Employees
2024 Enrollment and Change Request for Employees (Spanish)
Submission Deadlines and Late Application Policy
Submission Deadlines for 2023Covered California for Small Business (CCSB) will accept new business submissions through the first five business days of the month for same month coverage, provided a New Business Late Submission Acknowledgement Form is signed and submitted with the enrollment application. Be advised that the New Business Late Submission Acknowledgement Form is an optional form. If the group does not agree to the submission acknowledgement, the effective date will be the first of the month following the requested effective date.
Existing CCSB Customers
Employer Guide
Please refer to our Employer Guide for information on managing your company’s health and dental plans.
Employer Change Forms
Use the Employer Change Form to make changes in your group’s reference plan, metal tier levels, and contribution levels or to change the address or ownership of your small business.
Employer Change Form (English)
Employer Change Form (Spanish)
Employee Change Forms
Use the Employee Change Form to add new employees, make changes due to a qualifying event, or open enrollment.
2024 Employee Change Form (English)
2024 Employee Change Form (Spanish)
Q3-Q4 2023 Employee Change Form for Effective Dates: 7/1/2023-12/1/2023
Q3-Q4 2023 Employee Change Form for Effective Dates: 7/1/2023 to12/1/2023 (Spanish)
Other Forms and Documents
COBRA forms (COBRA election form, COBRA cancellation form, sample COBRA termination notice and COBRA rights document)
Quick Reference Documents
How to Access or Order a Member ID Card
I'm an Employer
Information on setting up health insurance for small business
- Health and Dental Plans
- Get a Quote
- Apply Now
- How We Can Help Your Business
- Who Is Eligible
- Resources for Participating Employers
- Latest News and Employer Updates
- Tax Credits
- Applications and Forms
- About CCSB