This page gives you immediate access to Small Group Health Insurance Forms and Applications for California.
Aetna Forms & Applications For Small Groups - California
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Select a SubCategory...    Group Medical   |   Dental   |   Life & Disability   |   Vision
Company
Group Medical - EMPLOYEE
 Description Form # Rev Date Fillable
Aetna
Employee Enrollment and Change Form

 Use this form to enroll employee and their family. California Small Group Business (2-50 eligible employees).
GR-67834-3
10-09
Yes
Aetna
Employee Enrollment - Spanish
 Use this Spanish form to enroll employee and their family. California Small Group Business (2-50 eligible employees).
GR-67834-3-SP
4-09
Yes
Aetna
Employee Change of Coverage Form
For existing enrollments only.
GR-68313
10-09
Yes
Aetna
Employee Change of Coverage Form - Spanish
Spanish version.
GR-68313SP
10-09
Yes
Aetna
HSA Employee Enrollment Form
   
1-2010
  
Company
Group Medical - EMPLOYER
Description Form # Rev Date Fillable
Aetna
Employer Application

 California Small Group Business Employer Application for group coverage (2-50 eligible employees).
GR-96241-C
10-09
Yes
Aetna
Employer Application - Medicare

 
GR-68448-2
10-08
  
Aetna
Employer Enrollment Form - HSA

Aetna HealthFund® Health Savings Account (HSA) Enrollment (Small Group).  
1-2010
  
Aetna
Employer HSA Contribution

Small Group Business Employer HSA Contribution Form and Instruction Sheet.
GR-68112
10-06
Yes
Aetna
    
4-09
  
Company
Group Medical - OTHER
Description Form # Rev Date Fillable
Aetna
 Attending Physician Behavioral Health Statement.
GC-1493-2
6-03
Yes
Aetna
 Small Group Business COBRA/CAL.COBRA Questionnaire (For use in CA only). This form must be completed when replacing another group plan.
GR-68924
4-04
  
Aetna
  
GC-7
9-08
Yes
Aetna
  
GC-1395
3-04
Yes
Aetna
 Employee Request For Information.
GC-1502-2
8-03
Yes
Aetna
Domestic Partnership - Declaration

Declaration Of Domestic Partnership
N/A
3-09
  
Aetna
Domestic Partner Declaration of Termination

 Declaration Of Termination of Domestic Partnership
N/A
3-08
  
Aetna
    
1-09
  
Aetna
    
3-09
  
Aetna
 Reimbursement Request. Fillable Form.
GC-1578
12-06
Yes
Aetna
 Authorization For Release Of Protected Health Information.
GR-67938
3-03
  
Aetna
 Spanish Version
GR-67938-SP
3-03
  
Aetna
 HRA Reimbursement Request
GC-1593
11-07
Yes
Aetna
 Aetna HealthFund® Health Savings Account (HSA) Beneficiary Designation.
GS-1546-1
10-05
  
Aetna
 Medical Benefits - Claim Instructions and form.
GC-7-39
2-04
  
Aetna
 Mental Health Provider's Statement.
GC-1422-4
6-02
Yes
Aetna
 California Group Health Coverage Employer Notice of Occurrence of Qualifying Event for Right to Continuation Coverage under CalCobra Consumer Markets 2-19 size groups.
GR-67564
5-04
Yes
Aetna
 For all new business sales where leased employees are involved.  
2-09
  
Aetna
 Commercial Prescription Drug Claim Form.
GC-1360
2-07
Yes
Aetna
Proof of Eligibility

 Proof of Eligibility Form For Small Employer (2-50) Sole Proprietors, Partners or Corporate Officers (To be used for eligible individuals that are not reported on a quarterly wage and tax form).  
10-06
Yes
Aetna
    
1-2010
  
Aetna
 Agreement to the establishment of an insurance trust fund for the purposes of implementing a Trust Agreement, and to designation of the Chase Manhattan Bank Delaware, DE, as "Trustee" for the Fund and Agreement Form.
GR-67987
7-03
Yes
Aetna
    
3-09
  
Aetna
 Coverage for a Special Dependent Child.
GR-67814
11-03
Yes
Aetna
 Cancellation Opt-Out FSA Form. If you are a member of an Aetna medical, dental or pharmacy plan, Streamline is a way for you to have your Health Care Flexible Spending Account claims paid without filling out a claim form. Your employer has automatically enrolled you in the Streamline option if you have signed up for a Health Care Flexible Spending Account.
GC-1579
1-07
  
Aetna
 Cancellation Opt-Out HRA Form. If you are a member of an Aetna medical, dental or pharmacy plan, Streamline is a way for you to have your Health Care Flexible Spending Account claims paid without filling out a claim form. Your employer has automatically enrolled you in the Streamline option if you have signed up for a Health Care Flexible Spending Account.
GC-1594
11-07
  
Aetna
  
GC-1395
3-06
Yes
Select a SubCategory...    Group Medical   |   Dental   |   Life & Disability   |   Vision
Company
Dental
 Description Form # Rev Date Fillable
Aetna
Dental Claim

Dental Benefits - Claim Instructions and Form
GC-8-13
3-07
 Yes
Aetna Spanish Version
GC-8-5-SP
1-04
 Yes
Aetna
Employer Dental / Life Group Election

 For Employers. California Small Group Business. This application is to be used by existing Aetna Small Groups within 60 days of the original Aetna Medical effective date.
GR-68107-2
3-09
 Yes
Aetna
Employee Dental / Life Group Election

 For Employees. California Small Group Business. This application is to be used by existing Aetna Small Groups within 60 days of the original Aetna Medical effective date.
GR-68108-2
1-09
 Yes
Company
Life Insurance
Description Form # Rev Date Fillable
Aetna Proof of Death - Group Life Insurance and Group Accidental Death Benefit Request.
GC-1373
3-04
 Yes
Aetna Spanish Version
GC-1373-SP
3-04
  
Company
Vision
 Description Form # Rev Date Fillable
Aetna N/A        
< Go Back    OR view forms & apps for:
Aetna  |  American Fidelity  |  Anthem Blue Cross  |  Blue Shield  |  California Choice  |  coPower  |  First Horizon  |  The Hartford  |  Health Net  |  HSA Bank
HSA California  |  Kaiser  |  Kaiser Choice Solution  |  New Dental Choice  |  Premier Access  |  Sharp  |  Sterling HSA  |  The Standard  |  UHC / PacifiCare  |  Unum
Western Health Advantage