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.
- Employer Application (includes medical and optional benefits information).
Quarterly/Annual Wage Report:
- Required for:
- Groups with 1-9 medically enrolling employees
- Virgin groups (regardless of group size)
- Groups with a lapse of coverage of more than 3 months
- Groups with a variance of 10% or more between the number of employees enrolling and the number of employees on the most recent prior carrier bill
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 Statement - Effective 1/1/2016:
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).
- Minimum Premium Deposit Check:
Employer may submit a copy of the group’s premium check, payable to CaliforniaChoice at case submission. Original check(s) 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. CONEXIS will be directly.
- Initial Payment Form (One-Time ACH) - Effective 4/1/2018
- Employee Application (and dependent waivers, if dependents not enrolling).
Disabled Dependent Certification - Effective 7/1/2014 (Current)
- 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 unless employer contribution is 100%.
- Group's home office must be located in California (Principal Executive Office).
- 51+% of eligible employees must reside in California.
- Groups coming from Kaiser Permanente to CaliforniaChoice may only apply at their anniversary.
- 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 Licencing - CA Agent Agreement - Effective 2/1/2012 (Current)
NOTE: PLEASE MAKE A PHOTOCOPY OF YOUR CASE FOR YOUR RECORDS PRIOR TO SUBMISSION
|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
or contact your Word & Brown Representative.