Printing Applications and Forms
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Administration Instructions for Groups

Employee Application/Deletion or Change Form

Please use the Individual application for adding a new employee, deleting an existing
employee or changing dependent status on an existing employee's coverage. 
You can also use our web forms to report these changes




Cal-COBRA groups will give us the members address upon termination of coverage and we will generate the Cal-COBRA election form and invoice the member directly for the coverage. 

Federal COBRA groups will need to issue a COBRA form upon the qualifying event.  
Click here for an Adobe Acrobat file of the Federal COBRA form.  
Members who extend coverage under Federal COBRA will be invoiced with the group and the individual premium collection is done by the group.

Please follow this link for a definition of Federal COBRA vs. Cal-COBRA and to notify us which COBRA regulations apply to your group.


Click here to view and print Certificates and Plan descriptions