Effective Date: 07/01/2025 - 12/01/2025
To assist Employers with the healthcare administration of new hires, terminations, benefit and policy changes, etc
Effective Date: 01/01/2026 - 06/01/2026
To assist Employers with the healthcare administration of new hires, terminations, benefit and policy changes, etc
Effective Date: 07/01/2021 - 06/01/2026
*FILLABLE* Must be completed by broker to sell CaliforniaChoice program. Commissions will not be paid until received.
Effective Date: 07/01/2021 - 06/01/2026
*FILLABLE* Must be completed by broker to sell CaliforniaChoice program. Commissions will not be paid until received.
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 07/01/2025 - 12/01/2025
Census Enrollment Spreadsheet for New Business only. Must be accompanied by the CC 0570 Employer Census Enrollment Spreadsheet Attestation.
Effective Date: 01/01/2026 - 06/01/2026
Census Enrollment Spreadsheet for New Business only. Must be accompanied by the CC 0570 Employer Census Enrollment Spreadsheet Attestation.
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2026
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 01/01/2024 - 12/01/2024
Use when you are a CaliforniaChoice member and no longer employed with the current employer but wish to continue coverage on COBRA.
Alert: Not used for initial enrollment.
Use this form to allow Choice Admin to deposit your commissions directly into a specified bank account.
Effective Date: 04/01/2024 - 08/01/2024
For employees to enroll in the CaliforniaChoice program
Effective Date: 09/01/2024 - 12/01/2024
For employees to enroll in the CaliforniaChoice program * Fillable*
Effective Date: 01/01/2025 - 03/01/2025
For employees to enroll in the CaliforniaChoice program * Fillable*
Effective Date: 04/01/2025 - 06/01/2025
*Fillable* for employees to enroll in the CaliforniaChoice program
Effective Date: 07/01/2025 - 12/01/2025
*Fillable* for employees to enroll in the CaliforniaChoice program
Effective Date: 01/01/2026 - 06/01/2026
*Fillable* for employees to enroll in the CaliforniaChoice program
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 04/01/2024 - 08/01/2024
Effective Date: 06/01/2024 - 08/01/2024
*Fillable*To be completed by the Employer and Broker at initial enrollment.
Effective Date: 01/01/2025 - 03/01/2025
*Fillable*To be completed by the Employer and Broker at initial enrollment.
Effective Date: 04/01/2025 - 06/01/2026
*Fillable*To be completed by the Employer and Broker at initial enrollment.
Required Attestation when using the CC 1276 Census Enrollment Spreadsheet for New Business enrollment
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 07/01/2024 - 09/01/2024
Effective Date: 10/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 10/01/2025
Effective Date: 10/01/2025 - 12/01/2025
Effective Date: 07/01/2025 - 10/01/2025
Effective Date: 07/01/2024 - 09/01/2024
Effective Date: 10/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 10/01/2025
Effective Date: 07/01/2025 - 10/01/2025
Effective Date: 10/01/2025 - 12/01/2025
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2026
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2026
Effective Date: 07/01/2024 - 08/01/2024
Effective Date: 09/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 07/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 07/01/2024 - 08/01/2024
Employee and dependent rates for groups with an effective or renewal date of 7/1/2024 through 8/1/2024
Effective Date: 09/01/2024 - 09/01/2024
Employee and dependent rates for groups with an effective or renewal date of 9/1/2024 through 9/1/2024
Effective Date: 10/01/2024 - 12/01/2024
Employee and dependent rates for groups with an effective or renewal date of 10/1/2024 through 12/1/2024
Effective Date: 01/01/2025 - 03/01/2025
Employee and dependent rates for groups with an effective or renewal date of 1/1/2025 through 3/1/2025
Effective Date: 04/01/2025 - 06/01/2025
Employee and dependent rates for groups with an effective or renewal date of 4/1/2025 through 6/1/2025
Effective Date: 07/01/2025 - 09/01/2025
Employee and dependent rates for groups with an effective or renewal date of 7/1/2025 through 9/1/2025
Effective Date: 10/01/2025 - 12/01/2025
Employee and dependent rates for groups with an effective or renewal date of 10/1/2025 through 12/1/2025
Effective Date: 01/01/2026 - 03/01/2026
Employee and dependent rates for groups with an effective or renewal date of 1/1/2026 through 12/1/2026
Effective Date: 04/01/2026 - 06/01/2026
Employee and dependent rates for groups with an effective or renewal date of 1/1/2026 through 12/1/2026
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 01/01/2025 - 12/01/2025
Effective Date: 01/01/2020 - 12/01/2024
Effective Date: 01/01/2020 - 12/01/2024
Effective Date: 01/01/2019 - 12/01/2019
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 04/01/2025 - 06/01/2026
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 10/01/2024 - 12/01/2024
Effective Date: 07/01/2025 - 08/01/2025
Effective Date: 09/01/2025 - 09/01/2025
Effective Date: 10/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 04/01/2025 - 06/01/2025
Effective Date: 01/01/2025 - 03/01/2025
Effective Date: 07/01/2024 - 08/01/2024
Effective Date: 09/01/2024 - 09/01/2024
Effective Date: 01/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 01/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 01/01/2026 - 06/01/2026
Effective Date: 01/01/2024 - 12/01/2024
Effective Date: 01/01/2025 - 12/01/2025
Effective Date: 01/01/2026 - 06/01/2026