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C12914-NEW 1-16 Employee Application - For 1 to 100 Employees 1-16

C12914-NEW 1-16 Employee Application - For 1 to 100 Employees 1-16 2025

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The document is a Small Business Employee Enrollment Form for Blue Shield of California, effective January 1, 2016. It collects subscriber information, reasons for application, health plan selections, and specialty benefits options including dental, vision, and life insurance. The form also includes sections for dependent information, COBRA enrollment, and privacy disclosures. Employees must provide accurate information to ensure timely processing of their enrollment.

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