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.
Group Enrollment Checklist
To ensure prompt processing, please make sure to include the following documents:
All documents below must be submitted at the time of application.
- A signed original Employer Group Application - Effective 1/1/2018
- A copy (all pages) of the most recent state Quarterly Wage and Tax Report (DE-9C).
- If the group has not been in business long enough to have a DE-9C, six weeks of payroll, including withholdings, may be submitted.
- For all employees that don’t appear on the current DE-9C, a copy of the most recent payroll is required.
- Copy of Worker’s Compensation.
- To reconcile the DE-9C, please indicate next to each employee’s name one of the following:
- T- Terminated (including termination date)
- E- Eligible and enrolling
- W- Eligible and waving coverage
- A copy of the current carrier’s most recent billing statement (including all pages). Employees appearing on the current bill with a reported termination date of 90 days or greater will be required to complete a COBRA application or waiver form as verification of their eligibility to continue or decline coverage.
- Employee Enrollment Form - Effective 1/1/2018
- Completed and signed by all eligible employee(s) enrolling/waiving coverage.
- If Medicare is primary, a copy of each employee’s Medicare card is required to verify enrollment in parts A and B. A copy of the Medicare card is also required to confirm participation requirements.
- First month premium check made payable to CCHP.
- If Broker is involved, a Broker of Record letter is required.
Proof of Ownership documentation:
Required for all groups enrolling and owner-only groups of any size when the owners do not appear on the DE-9C or payroll records.
Must list each person’s first and last name. Paperwork must be filled out with the state or country documentation may include:
- California Business License, or
- Fictitious Business Name Statement, if any, or
- Most recent IRS Schedule C (Form 1040)
Partnership / LLP:
- Partnership Agreement signed by each partner plus a federal EIN assignment letter, or
- IRS Schedule K-1 (Form 1065) for all enrolling partners or Partnership Agreement signed by each partner.
- Statement of Information
- S-Corps: IRS Schedule K-1 (Form1120S) for all enrolling owners/officers.
- C-Corps: IRS Form 1120 (pages 1 & 2) which includes “Schedule E”
- LLC Agreement signed by all managers/members/parties or copies of appropriate tax returns (follow the guidelines for an S-Corp, Partnership or Sole Proprietorship based on how the LLC was formed)
- Statement of Information (From LLC-12)
New/Start-up Businesses represent a unique opportunity. These groups typically meet all the underwriting requirements with the exception of the length of time in business. CCHP will give consideration to groups that have been in business for at least six (6) weeks, but retains the right to defer the group until the California Small Group legal requirements have been met. To obtain approval for a New/Start-up Business, the following may be required:
- LPayroll records or applicable filing indicating the length of time the group has been in business. These documents must span the twelve (12) weeks preceding the effective date and demonstrat one or more eligible employees for the entire period. Payroll records must include all pages for all pay periods and list the following:
- Company name
- Date of pay periods
- Employee names, wages paid, withholdings and grand totals
- Individual payroll / pay stubs, estimated payroll, payroll sumarries or handwritten journals are not deemed acceptable.
This documentation is used to verify that the prospective client is a leigitmate, active small group eligible or coverage. The information is also used to verify that an owner, officer or partner is actively engaged in the business and eligible for coverage. CCHP may conduct online searches to validate filings and other documentation. CCHP may decline a group for coverage if a search is not successful.
|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.