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In order to apply for Small Business Group Coverage in California
You must be an Owner* of a Business which employs 2 - 50 employees.* Owner is defined as employees for this purpose.
For example a husband and wife who own a business and share the operation of the business could be defined as two (2) subscribers.
The business must have been operating for half of the previous quarter, and must possess a current valid city business license, a current DE-6 filing, or a fictitious business name statement DBA, from your local County Recorder's office. Or a Resellers permit or professional license i.e., contractors, cosmetologists, physicians, etc. AND the previous years profit and loss statement (schedule C) from your income tax filing
Following is a list of the business information needed.Name of the Business
Address
City, State and Zip
Phone / Fax
Type of Business
How long in Business
Owner's Name & SSN
Number of Employees
Number of Eligible Employees
Exempt Cobra Yes / No - (No, less than 20 Employees)
Days to Eligibility (New Hire Only)
Percentage of Premium paid for Employees (50 - 100%)
Choice/ Enrollment in what Plan (# 2 thru 5)
SignatureInformation needed on Enrollment application
Name of Employee or Partner applying for coverage
Address, City, State and Zip
Phone / Fax
Date of Birth
Family information:
Names, Dates
of birth, SS# etc.
Name and City of Employer
Other Forms Needed
D-E 6 Quarterly Filing if your company has eligible employees
or
Partnership Form completed and signed
by Partners (supplied)
or
For non profit organizations: Call
for information 888-424-6208
