California - Small Business Employee Enrollment Form 2026

1. Click ‘Get Form’ to open the California - Small Business Employee Enrollment Form in the editor.
2. Begin by filling out the employer section, including the Group Name/Number and Requested Effective Date of Insurance. Ensure all fields are completed accurately to expedite processing.
3. In Section A, provide your personal information such as First Name, Last Name, Date of Birth, and Social Security Number. Select your Marital Status and indicate if you have ever been a UnitedHealthcare member.
4. Complete Section B for Dependent Information. List all dependents enrolling in coverage, including their names, dates of birth, and relationships to you.
5. In Section C, select the medical and dental plans you wish to enroll in by writing down the Plan Codes or descriptions as required.
6. If applicable, complete Section D regarding any other medical insurance coverage you or your dependents may have.
7. Finally, review all sections for accuracy before signing in Section F to confirm your application.

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