AEGIS PACIFIC
Insurance Service
Blue Shield of California Forms
Employee Applications for 2-50 Employee
(11/06)
Employer Questionnaire for 15-50 Enrolling Employees
(07/05)
Request for Contract Change
(02/07)
Small Group Enrollment Affidavit
Subscriber Change Request Forms
(06/05)
This form is used to make changes in group subscriber information and states. Examples: effective date, membership number, plan choice, add or delete dependents, change of address
Subscriber Change Request Forms - Spanish Version
(06/05)
This form is the same as above translated to Spanish.
Request for Proposal Form
Employer Notification of Qualifying Event Under Cal COBRA
(SB719) (C13140 06/00)
This form is completed by the employer at the time of the qualifying event of the employee and mailed or faxed to Blue Shield.
Affidavit of Domestic Partnership
This form is completed by the employee at enrollment.
Sub-Producer Information Form
This form is completed by an agent when signing up with AEGIS PACIFIC as a sub-producer.
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