C12914 (4/21) Employee Application 1 of 9
Blue Shield of California is an independent member of the Blue Shield Association
C12914-FF (4/21)
Small Business Employee Enrollment Form
Blue Shield of California and
Blue Shield of California Life & Health Insurance Company
Effective April 1, 2021
Subscriber information – Please note: Missing information may delay processing.
Additional subscriber information is located in Section 2.
Subscriber’s last name First name MI
Social Security number
Reason for application – Please indicate the reason for your enrollment below:
New group enrollment
Group effective date:
New hire Rehire
Date of rehire:
Open enrollment
Renewal date:
COBRA/Cal-COBRA enrollment
New spouse/dependent
Date of marriage/birth/adoption:
Other qualifying event
(specify):
Qualifying event date:
Section 1a – Health plan selection Select one health plan from the package(s) offered by your employer.
Blue Shield of California Off-Exchange Package for Small Business
PPO plansFull PPO Network
Platinum Full PPO 0/0 OffEx
Platinum Full PPO 0/10 OffEx
Platinum Full PPO 250/10 OffEx
Platinum Full PPO 250/15 OffEx
Gold Full PPO 0/25 OffEx
Gold Full PPO 500/30 OffEx
Gold Full PPO 750/30 OffEx
Gold Full PPO 1200/35 OffEx
Silver Full PPO 1950/50 OffEx
Silver Full PPO 2225/50 OffEx*
Silver Full PPO 2400/55 OffEx
Bronze Full PPO 6250/70 OffEx
Bronze Full PPO 6850/65 OffEx
Bronze Full PPO 7500/50 OffEx
HSA-compatible HDHP plansFull PPO Network
Gold Full PPO Savings 1750/15% OffEx
Silver Full PPO Savings 2100/25% OffEx
Silver Full PPO Savings 2600/35% OffEx
Bronze Full PPO Savings 5700/40% OffEx
Bronze Full PPO Savings 7000 OffEx
HSA-compatible HDHP plansTandem PPO Network
Gold Tandem PPO Savings 1750/15% OffEx
Silver Tandem PPO Savings 2100/25% OffEx
Silver Tandem PPO Savings 2600/35% OffEx
Bronze Tandem PPO Savings 5700/40% OffEx
Bronze Tandem PPO Savings 7000 OffEx
Tandem PPO plans – Tandem PPO Network
Platinum Tandem
PPO 0/0 Off
E
x
Pla
tinum
Tandem PPO 0/10 OffEx
Platinum Tandem PPO 250/10 OffEx
Platinum Tandem PPO 250/15 OffEx
Gold Tandem PPO 0/25 OffEx
Gold Tandem PPO 500/30 OffEx
Gold Tandem PPO 750/30 OffEx
Gold Tandem PPO 1200/35 OffEx
Silver Tandem PPO 1950/50 OffEx
Silver Tandem PPO 2225/50 OffEx*
Silver Tandem PPO 2400/55 OffEx
Bronze Tandem PPO 6250/70 OffEx
Bronze Tandem PPO 6850/65 OffEx
Bronze Tandem PPO 7500/50 OffEx
Access+ HMO plans – Access+ HMO Network
Platinum Access+ HMO
0/20 OffEx
Platinum Access+ HMO 0/25 OffEx
Platinum Access+ HMO 0/30 OffEx
Gold Access+ HMO 0/30 OffEx
Gold Access+ HMO 500/35 OffEx
Gold Access+ HMO 1000/35 OffEx
Gold Access+ HMO 1500/35 OffEx
Silver Access+ HMO 2350/65 OffEx
Local Access+ HMO plans Local Access+ HMO Network
Platinum Local Access+ HMO
0/20 OffEx
Platinum Local Access+ HMO 0/25 OffEx
Platinum Local Access+ HMO
0/30 OffEx
Gold Local Access+ HMO 0/30 OffEx
Gold Local Access+ HMO 500/35 OffEx
Gold Local Access+ HMO 1000/35 OffEx
Gold Local Access+ HMO 1500/35 OffEx
Silver Local Access+ HMO 2350/65 OffEx
Trio HMO plans – Trio ACO HMO Network
Platinum Trio HMO 0/20 OffEx
Platinum Trio HMO 0/25 OffEx
Platinum Trio HMO 0/30 OffEx
Gold Trio HMO 0/30 OffEx
Gold Trio HMO 500/35 OffEx
Gold Trio HMO 1000/35 OffEx
Gold Trio HMO 1500/35 OffEx
Silver Trio HMO 2350/65 OffEx
* The Silver Full PPO 2225/50 OffEx and Silver Tandem PPO 2225/50 OffEx offer enhanced coverage for members diagnosed with diabetes, asthma, COPD, and CAD.
Blue Shield of California Mirror Package for Small Business
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental
Blue Shield Platinum 90 PPO 0/15 + Child Dental
Blue Shield Trio Gold 80 HMO 250/35 + Child
Dental
Blue Shield Gold 80 PPO 350/25 + Child Dental
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental
Blue Shield Silver 70 PPO 2250/50 + Child Dental
Blue Shield Bronze 60 PPO 6300/65 + Child Dental
C12914 (4/21) Employee Application 2 of 9
Section 1b – Specialty benefits – dental,* vision,* and life insurance* plan selection
* Only benefits your employer group offers are available for selection. Any benefits selected that are not offered by your employer group will be omitted from your enrollment.
Select specialty plan(s) from the package offered by your employer.
Section SB1 – Dental benefits
Dental HMO plans
DHMO Basic DHMO Standard DHMO Plus DHMO Deluxe DHMO Voluntary
Dental PPO plans
Smile
SM
Value 50/1500/No Ortho/MAC/NR
Smile
SM
50/1500/No Ortho/MAC/NR
Smile
SM
Plus 50/1500/Ortho/MAC/NR
Smile
SM
Basic 75/1000/No Ortho/MAC/NR
Smile
SM
Basic 50/1000/No Ortho/MAC
Smile
SM
Basic 50/1000/Ortho/U85
Smile
SM
Plus 50/1500/No Ortho/MAC
Smile
SM
Plus 50/1500/No Ortho/MAC/WP*
Smile
SM
Deluxe 50/1500/Ortho/MAC/NR
Smile
SM
Deluxe 2000 50/2000/No Ortho/MAC/NR
Smile
SM
Deluxe Plus 2000 50/2000/Ortho/MAC/NR
Smile
SM
Deluxe Gold 50/1500/Ortho/U85/NR
Smile
SM
Plus Gold 50/1500/Ortho/U85/NR
Smile
SM
Plus Gold 50/1500/Ortho/U80
Smile
SM
Plus Gold 50/1500/No Ortho/U80
Smile
SM
Plus Gold 50/1500/Ortho/U80/ADV
Smile
SM
Plus Gold 50/1500/Ortho/U90/ADV
Smile
SM
Plus Gold 50/1500/No Ortho/U90/ADV
Smile
SM
Plus Gold 50/2500/Ortho/U90/ADV
Smile
SM
Plus Gold 50/2500/No Ortho/U90/ADV
Ultimate Dental PPO for Small Business 50/2000/No Ortho/MAC/NR
Ultimate Dental Plus PPO for Small Business 50/2000/Ortho/MAC/NR
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U80
Ultimate Dental PPO for Small Business 50/2000/Lifetime Ortho/U90
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U90
Voluntary Dental PPO plans*
Smile
SM
Basic Voluntary 75/1000/No Ortho/MAC/NR
Smile
SM
Basic Voluntary 50/1000/No Ortho/MAC
Smile
SM
Basic Voluntary 50/1500/Ortho/U80
Smile
SM
Basic Voluntary 50/1000/No Ortho/U80 (No Wait)
Dental In-Network Only (INO) plans
(only available for groups enrolled in these plans prior to 12/31/2018)
Smile
SM
INO Dental Plan 50/1500/Endo-Perio 80%/Ortho
Smile
SM
INO Dental Plan 50/1500/Endo-Perio 80%/No Ortho
Smile
SM
INO Dental Voluntary Plan 50/1500/Endo-Perio 50%/Ortho*
Smile
SM
INO Dental Voluntary Plan 50/1500/Endo-Perio 50%/No Ortho*
Smile
SM
INO Dental Plan 50/2500/Endo-Perio 80%/Ortho
Smile
SM
INO Dental Plan 50/2500/Endo-Perio 80%/No Ortho
Smile
SM
INO Dental Voluntary Plan 50/2500/Endo-Perio 50%/Ortho*
Smile
SM
INO Dental Voluntary Plan 50/2500/Endo-Perio 50%/No Ortho*
Dental PPO plans (only available for groups enrolled in these plans prior to 12/31/2018)
Ultimate Dental PPO for Small Business 50/2000/MAC
Ultimate Dental Plus PPO for Small Business 50/2000/MAC
Smile
SM
Deluxe 2000 50/2000/No Ortho/MAC
Smile
SM
Deluxe Plus 2000 50/2000/Ortho/MAC
Smile
SM
Deluxe 50/1500/Ortho/MAC
Smile
SM
Deluxe Gold 50/1500/Ortho/U85
Smile
SM
50/1500/No Ortho/MAC
Smile
SM
Plus 50/1500/Ortho/MAC
Smile
SM
Value 50/1500/No Ortho/MAC
Smile
SM
Plus Gold 50/1500/Ortho/U85
Smile
SM
Basic 75/1000/No Ortho/MAC
Smile
SM
Basic Voluntary 75/1000/No Ortho/MAC
* Voluntary dental plans require a minimum of one (1) enrolling, eligible employee.
Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).
This Voluntary plan does not include Waiting Periods submission of proof of any prior coverage is not required.
ADV stands for Advantage. ADV plans incentivize members to use in-network providers. NR stands for No Rollover.
Section SB2 – Vision coverage
Vision coverage*
Ultimate Vision for Small Business (12-12-12)
Ultimate Vision Plus 0/0/150/120
Ultimate Vision 0/0/150
Ultimate Vision Plus 10/25/150/120
Ultimate Vision 10/25/150
Ultimate Vision 0/0/120
Ultimate Vision 10/25/120
Ultimate Vision Voluntary 10/25/150
1
Preferred Vision for Small Business (12-12-24)
Preferred Vision Plus 0/0/150/120
Preferred Vision 0/0/150
Preferred Vision Plus 10/25/150/120
Preferred Vision 10/25/150
Preferred Vision 0/0/120
Preferred Vision 10/25/120
Preferred Vision Voluntary 10/25/120
1
Basic Vision for Small Business (12-24-24)
Basic Vision Plus 0/0/150/120
Basic Vision 0/0/150
Basic Vision Plus 10/25/150/120
Basic Vision 10/25/150
Basic Vision 0/0/120
Basic Vision 10/25/120
Basic Vision Voluntary 10/25/120
1
Other (please specify) _______________________
* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).
1 Voluntary vision plans require a minimum of one (1) enrolling, eligible employee.
Subscriber’s last name First name MI Social Security number
C12914 (4/21) Employee Application 3 of 9
Section SB3 – Life/AD&D insurance
Group term life insurance* (Note: Please fill out if group is offering Blue Shield Life and life is being requested).
Employee information
Full-time employment date Average hours worked per week Rehire date Job class/occupation Earnings $ _________________
(excluding overtime, bonuses, etc.)
c Hour c Week c Month c Year
Designation of beneficiary
Community property laws – If you are married or in a domestic partnership, reside in a community property state (Arizona, California, Idaho, Louisiana, Nevada, New Mexico,
Texas, Washington, or Wisconsin), and name someone other than your spouse/domestic partner as beneficiary, it is possible that payment of benefits will be delayed or disputed
unless your spouse/domestic partner also signs the beneficiary designation.
I agree to the stated beneficiary designation(s).
Spouse/domestic partner signature: Date:
Spouse/domestic partner name (please print)
Primary beneficiary – Blue Shield Life will pay the life insurance benefits to the primary beneficiary/beneficiaries identified. An employee may designate more than one primary
beneficiary. Please show percentages for each primary beneficiary in the “% of benefits” column to total 100% of benefits. If the percentage is not defined, the benefits will be
distributed equally to those primary beneficiaries who survive the employee. To designate more than two primary beneficiaries, please provide on a separate sheet of paper, which
is signed and dated by the employee, and attach to this form.
First name MI Last name Social Security number Relationship Date of birth % of benefits
Address City State ZIP code
First name MI Last name Social Security number Relationship Date of birth % of benefits
Address City State ZIP code
Contingent beneficiary – Proceeds will be paid to a contingent beneficiary only if no designated primary beneficiary survives the insured.
First name MI Last name Social Security number Relationship Date of birth % of benefits
Address City State ZIP code
Information on benefit amounts
Please contact your benefits administrator for more information regarding your group life insurance coverage. Coverage granted to individuals listed in this enrollment
form shall be subject to all provisions and limitations stated in the Blue Shield of California Life & Health Insurance Company group life insurance policy.
Number of eligible dependents:
Basic Dependent Life Insurance: c Yes c No
Employee Basic Life and AD&D Insurance amount: $ Amount of coverage requested for dependent(s): $
* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).
A46897
Subscriber’s last name First name MI Social Security number
C12914 (4/21) Employee Application 4 of 9
Section 2a – Subscriber information
Note: Social Security numbers are required per CMS.
Social Security number Employer (group) name Blue Shield Group ID
Last name First name MI
Home (physical) address (no P.O. Box addresses) City State ZIP code
Mailing address (if different from home address) City State ZIP code
Work phone number: Home phone number: Language preference:
c English c Spanish c Chinese c Vietnamese c Other
Email address (required)
By providing your email, you will automatically have access to blueshieldca.com, and be enrolled in paperless communications. You can change your preferences at any time through
your online account.
Date of birth:
Gender: c Male c Female Marital Status: c Single c Married c Domestic partner
Do you have any eligible dependent children under the age of 26? c Yes c No How many? How many are enrolling?
Please tell us about yourself. How would you describe your race or ethnicity? These questions are optional and are only used to help ensure all members have the same access to the
highest quality of care.
1. Are you of Hispanic or Latino origin? 2. If yes, please select one:
3. Which race(s) do you identify with? (select one)
c Yes
c No
c Unknown
c Declined
c Cuban
c Guatemalan
c Mexican, Mexican American, Chicano
c Puerto Rican
c Salvadoran
c 2 or more Ethnicities
c Other Hispanic, Latino, Spanish:
_______________________
c American Indian or Alaska Native.
c Asian Indian
c Black or African American
c Cambodian
c Chinese
c Filipino
c Guamanian or Chamorro
c Hmong
c Japanese
c Korean
c Laotian
c Native Hawaiian
c Samoan
c Vietnamese
c White
c 2 or more Races
c Other
c Unknown
c Declined
If there are applicable dependents included on your application, are all dependents listed of the same race and ethnicity as the primary applicant? c Yes c No
If you answered “No”, please include the race and ethnicity for each of your dependents in Part 4.
Section 2b – Employment information
Date of hire:
(Full time or part time as noted below. If orientation period is applied, the date
of hire is the first day after completion of the orientation period.)
Job title:
Job classication:
Employment status: Mark one option
I am a full-time employee actively working 30 hours or more per week for this employer. c Yes c No
I am a part-time employee actively working between 20-29 hours per week for this employer. c Yes c No
I am an existing COBRA participant or enrolling due to a COBRA qualifying event. c Yes c No If yes, complete section 7 (required).
Section 3 – HMO primary care physician/dental HMO provider assignment
This section is only required if you selected an HMO plan. If you selected a PPO plan, please proceed to Section 4.
HMO plan primary care physician selection
Would you like for Blue Shield to designate a primary care physician for you and your dependents who is located near your home or work?
c Yes, I would like Blue Shield to designate a primary care physician and/or dental HMO provider for me and my dependents.
c No, I would like to request a specic primary care physician and/or dental HMO provider for myself and my dependents (please specify below).
* Please note: If Blue Shield is unable to assign the primary care physician and/or Dental HMO provider you requested, Blue Shield will designate a provider. HMO primary
care physicians can be changed by visiting blueshieldca.com after enrollment.
HMO primary care physician name Provider number IPA/MG name Existing patient?
c Yes c No
Dental HMO provider name Provider number Dental group name Existing patient?
c Yes c No
Subscriber’s last name First name MI Social Security number
C12914 (4/21) Employee Application 5 of 9
Section 4 Dependent information
Please note: If the employee, spouse/domestic partner, or child dependent(s) are refusing coverage for any product offered by the group, the employee must complete and sign a
Refusal of Personal Coverage form at the end of this application instead of completing the section below. Blue Shield will enroll dependents under all plans that the employee is also
enrolled/enrolling in unless indicated otherwise.
Dependent type:
Spouse
Domestic partner
Gender:
Male
Female
Social Security number (required) Enrolling in all products selected by subscriber?
Yes No
If no, Refusal of Coverage attached? Yes No
First name MI Last name
Date of birth Address (if different from employee)
If different from Subscriber, which Race and Ethnicity does this dependent identify with?
HMO primary care physician name
Provider number IPA name Existing patient?
Yes No
Dental HMO provider name Provider number Dental group name Existing patient?
Yes No
Dependent type:
Dependent child
Other dependent child:
legal guardianship
Gender:
Male
Female
Social Security number (required) Enrolling in all products selected by subscriber?
Yes No
If no, Refusal of Coverage attached? Yes No
First name MI Last name
Date of birth Address (if different from employee)
If different from Subscriber, which Race and Ethnicity does this dependent identify with?
HMO primary care physician name
Provider number IPA name Existing patient?
Yes No
Dental HMO provider name Provider number Dental group name Existing patient?
Yes No
Dependent type:
Dependent child
Other dependent child:
legal guardianship
Gender:
Male
Female
Social Security number (required) Enrolling in all products selected by subscriber?
Yes No
If no, Refusal of Coverage attached? Yes No
First name MI Last name
Date of birth Address (if different from employee)
If different from Subscriber, which Race and Ethnicity does this dependent identify with?
HMO primary care physician name
Provider number IPA name Existing patient?
Yes No
Dental HMO provider name Provider number Dental group name Existing patient?
Yes No
Dependent type:
Dependent child
Other dependent child:
legal guardianship
Gender:
Male
Female
Social Security number (required) Enrolling in all products selected by subscriber?
Yes No
If no, Refusal of Coverage attached? Yes No
First name MI Last name
Date of birth Address (if different from employee)
If different from Subscriber, which Race and Ethnicity does this dependent identify with?
HMO primary care physician name
Provider number IPA name Existing patient?
Yes No
Dental HMO provider name Provider number Dental group name Existing patient?
Yes No
Subscriber’s last name First name MI Social Security number
C12914 (4/21) Employee Application 6 of 9
Dependent type:
Dependent child
Other dependent child:
legal guardianship
Gender:
Male
Female
Social Security number (required) Enrolling in all products selected by subscriber?
Yes No
If no, Refusal of Coverage attached? Yes No
First name MI Last name
Date of birth Address (if different from employee)
If different from Subscriber, which Race and Ethnicity does this dependent identify with?
HMO primary care physician name
Provider number IPA name Existing patient?
Yes No
Dental HMO provider name Provider number Dental group name Existing patient?
Yes No
Dependent type:
Dependent child
Other dependent child:
legal guardianship
Gender:
Male
Female
Social Security number (required) Enrolling in all products selected by subscriber?
Yes No
If no, Refusal of Coverage attached? Yes No
First name MI Last name
Date of birth Address (if different from employee)
If different from Subscriber, which Race and Ethnicity does this dependent identify with?
HMO primary care physician name
Provider number IPA name Existing patient?
Yes No
Dental HMO provider name Provider number Dental group name Existing patient?
Yes No
Dependent type:
Dependent child
Other dependent child:
legal guardianship
Gender:
Male
Female
Social Security number (required) Enrolling in all products selected by subscriber?
Yes No
If no, Refusal of Coverage attached? Yes No
First name MI Last name
Date of birth Address (if different from employee)
If different from Subscriber, which Race and Ethnicity does this dependent identify with?
HMO primary care physician name
Provider number IPA name Existing patient?
Yes No
Dental HMO provider name Provider number Dental group name Existing patient?
Yes No
Dependent type:
Dependent child
Other dependent child:
legal guardianship
Gender:
Male
Female
Social Security number (required) Enrolling in all products selected by subscriber?
Yes No
If no, Refusal of Coverage attached? Yes No
First name MI Last name
Date of birth Address (if different from employee)
If different from Subscriber, which Race and Ethnicity does this dependent identify with?
HMO primary care physician name
Provider number IPA name Existing patient?
Yes No
Dental HMO provider name Provider number Dental group name Existing patient?
Yes No
Subscriber’s last name First name MI Social Security number
C12914 (4/21) Employee Application 7 of 9
Dependent type:
Dependent child
Other dependent child:
legal guardianship
Gender:
Male
Female
Social Security number (required) Enrolling in all products selected by subscriber?
Yes No
If no, Refusal of Coverage attached? Yes No
First name MI Last name
Date of birth Address (if different from employee)
If different from Subscriber, which Race and Ethnicity does this dependent identify with?
HMO primary care physician name
Provider number IPA name Existing patient?
Yes No
Dental HMO provider name Provider number Dental group name Existing patient?
Yes No
Section 5 Other health plan information If enrolling due to a loss of coverage under a prior health plan
and/or to receive credit toward any employer waiting period, documentation is required to verify the date of the
qualifying event.
Does any person applying for coverage currently have health coverage or previously had health coverage at any time in the past six (6) months? Yes No
If yes, specify carrier:__________________________________________________
Type of coverage: Group Individual Medicare Covered California/State Health Insurance Exchange Other (specify): ____________________________
Policy/ID Date coverage began: Date ended (if coverage is active, please leave blank):
Documentation attached?
Yes No
Section 6 – Medicare information
Are you or any of your dependents currently covered by Medicare?
Please attach a copy of your Medicare card(s) and/or enter the type of coverage here:
Part A: Effective date: (mm/dd/yyyy) Part B: Effective date: (mm/dd/yyyy)
Yes No
Is Medicare eligibility due to end-stage renal disease (ESRD)?
If yes, please answer the following questions:
a) ___________________ (mm/dd/yyyy)
Type: Hemodialysis Self-dialysis (peritoneal)
b) If you had a kidney transplant, what was the date of the transplant: (mm/dd/yyyy)
Yes No
Section 7 – COBRA/Cal-COBRA group continuation coverage
Please complete this section only if enrolling for COBRA or Cal-COBRA group continuation coverage. Those individuals already enrolled in COBRA or Cal-COBRA coverage from a prior
carrier are eligible to continue that coverage with Blue Shield for the remaining duration of time allowed through COBRA and/or Cal-COBRA (as applicable). Proof of enrollment as a
COBRA/Cal-COBRA participant is required.
Please provide the name of the employee through whom group coverage was obtained prior to the qualifying event, in order to be eligible for COBRA/Cal-COBRA continuation coverage.
Employee last name
MI
Employee’s/subscriber’s Blue Shield ID (if applicable) Original qualifying event date
Qualifying event reason:
Termination or reduction in hours (last day worked)
Termination or reduction in hours due to disability
Divorce or legal separation
Entitlement to Medicare by covered employee
Attainment of maximum age for a dependent child
Death of covered employee
Termination of domestic partnership
Subscriber’s last name First name MI Social Security number
C12914 (4/21) Employee Application 8 of 9
Section 8 - Disclosure of personal and health information
At Blue Shield of California, we understand the importance of keeping your personal information private, and we take our obligation to do so very seriously. Blue Shield protects the
privacy and security of the personal information that we maintain, use, and disclose for purposes of administering your Blue Shield coverage.
Blue Shield obtains personal information about you and/or your covered dependents, including health and/or nancial information, from you, at your direction, and/or with your
permission. We are also permitted by federal and state law to obtain your personal information from other sources, including, for example, from your healthcare provider, insurer,
insurance support organization, health plan, or insurance agent. We use and disclose your personal information to administer your Blue Shield coverage and as otherwise permitted or
required by law. In doing so, we may disclose your personal information to others including, for example, a healthcare provider, insurer, insurance support organization, health plan, or
your insurance agent. Blue Shield will not disclose your personal information without your authorization except as permitted or required by law.
Blue Shield is required to provide you with a Notice of Privacy Practices (“Notice”) that describes your privacy rights, our obligations to protect your privacy, and how we use and
disclose your personal information with and without your specic authorization. When we use or disclose your personal information, we are bound by the terms of the Notice,
which applies to all records that we create, obtain, and/or maintain that contain your personal information. You will receive our Notice when you enroll for Blue Shield coverage.
You may also obtain a copy of our Notice by calling the customer service number on your Blue Shield member ID card or by visiting our website at blueshieldca.com/bsca/
documents/about-blue-shield/privacy.
Acknowledgement and signature
I acknowledge and agree: All information I have provided on this enrollment form is correct and true to the best of my knowledge and belief. I understand that it is the basis on
which coverage may be issued under the plan. I understand that if I have committed fraud or made an intentional misrepresentation of any material fact in conjunction with this
enrollment within 24 months of issuance, Blue Shield may pursue one of the following remedies: coverage may be cancelled, or the applicable premium may be adjusted, or, following
notice, coverage may be rescinded. I further authorize my employer to deduct from my earnings the contribution (if any) required toward the cost of this plan.
I understand that coverage does not become effective until this and my employer’s application have been approved by Blue Shield of California.
Signature of employee Date
Print employee name
All pages of this form are necessary to process your enrollment.
Missing information may delay processing.
If submitting for an existing Blue Shield plan, go to blueshieldca.com.
Subscriber’s last name First name MI Social Security number
C12914 (4/21) Employee Application 9 of 9
Refusal of Coverage form
Complete this form if you, your spouse, domestic partner, or child dependent(s) are refusing this group health, dental, vision, and/or life insurance coverage offered through the
employer. (The employer must retain a copy of this form to provide to Blue Shield upon request.) Please type or print. Use black ink. *Note: The employee’s Social Security number
is required for all eligible employees.
Employee name Social Security number Date of birth
Employer (Group) name Hire date State of residence
Marital status Married Yes No
Domestic partnership Yes No
Job title
Is the employee a full-time employee, working at least 30 hours per week for this employer? Yes No Or
Is the employee a part-time employee, working at least 20 hours per week for this employer? Yes No
Declining coverage for:
I decline health plan coverage for:
Myself and all dependents.
My spouse/domestic partner only
My children only
My spouse/domestic partner and children only
The following dependents only:
________________________________________
If dental plan offered, I decline dental plan coverage for:
Myself and all dependents.
My spouse/domestic partner
My children
My spouse/domestic partner and children
The following dependents only:
________________________________________
If vision plan offered, I decline vision plan coverage for:
Myself and all dependents
My spouse/domestic partner
My children
My spouse/domestic partner and children
The following dependents only:
________________________________________
If life insurance plan offered, I decline life plan coverage for:
Myself
Reason employee is declining health coverage
OTHER EMPLOYER HEALTH COVERAGE
Enrolling as a dependent or an employee on this group health plan
Covered by this employer’s other health plan (through another carrier)
Covered by another employers health plan, including COBRA or Cal-COBRA coverage, through your spouse/domestic
partner, parent, or previous employer
OTHER NON-EMPLOYER HEALTH COVERAGE
Covered by an individual/family health plan
Covered by Government program, including Medicare, Medi-Cal, Healthy Families Program, TRICARE, Indian Health
Service, Tribal and Urban Indian Health Program, and Veterans Health Administration (VA)
OTHER REASONS
Reason employee is declining dental coverage
OTHER DENTAL COVERAGE
Enrolling as a dependent or an employee on this group dental plan
Covered by another employers dental plan, including COBRA or Cal-COBRA dental coverage, through your spouse/
domestic partner, parent, or previous employer
Covered by an individual/family dental plan
OTHER REASONS
Reason employee is declining vision coverage
OTHER VISION COVERAGE
Enrolling as a dependent or an employee on this group vision plan
Covered by another employers vision plan, including COBRA or Cal-COBRA vision coverage, through your spouse/
domestic partner, parent, o
r previous employer
Covered by an individual/family vision plan
OTHER REASONS
Reason employee is declining life insurance coverage
OTHER LIFE INSURANCE COVERAGE
Covered by another employer’s life insurance coverage through your spouse/domestic partner, or parent
OTHER REASONS
Cost of coverage
Do not need or do not want coverage
I acknowledge that the coverage available to me has been explained to me by my employer and I know that I have every right to enroll in this coverage and I have decided not to enroll
myself and/or my dependent(s), if any. I now decline to enroll myself, my spouse/domestic partner, and/or my child dependent(s) in my employer’s group health plan. I have made this
If I am declining enrollment for myself or my dependents because of other health coverage or because the employer stops contributing toward this coverage, I acknowledge that I may
be able to enroll myself and my dependents in this plan if I request enrollment within 60 days after my or my dependents’ other coverage ends or after the employer stops contributing
toward the other coverage.
In addition, if I acquire a new dependent as the result of marriage/domestic partnership, birth, adoption or placement for adoption, I acknowledge that I, and my dependents, may request
enrollment in my employer’s health plan by applying for that coverage within 60 days of the marriage/domestic partnership, birth, adoption, or placement for adoption. I also acknowledge
that if I, or my dependents, become eligible for the Healthy Families or the Medi-Cal Premium Assistance programs, I or my dependents may request enrollment in my employer’s health plan
by applying for coverage within 60 days of the notice of eligibility for these premium assistance programs.
within 60 days. Otherwise, I understand I may not enroll myself and/or my dependents in my employer’s health plan until the earlier of the end of my employer’s next open enrollment
period or 12 months.
Signature of employee Date
Blue Shield of California
Notice Informing Individuals about Nondiscrimination
and Accessibility Requirements
Discrimination is against the law
Blue Shield of California complies with applicable state laws and federal civil rights laws, and does
not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status,
gender, gender identity, sexual orientation, age, or disability. Blue Shield of California does not
exclude people or treat them differently because of race, color, national origin, ancestry, religion,
sex, marital status, gender, gender identity, sexual orientation, age, or disability.
Blue Shield of California:
Provides aids and services at no cost to people with disabilities to communicate effectively
with us such as:
- Qualified sign language interpreters
- Written information in other formats (including large print, audio, accessible electronic
formats, and other formats)
Provides language services at no cost to people whose primary language is not English such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact the Blue Shield of California Civil Rights Coordinator.
If you believe that Blue Shield of California has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, ancestry, religion, sex, marital status,
gender, gender identity, sexual orientation, age, or disability, you can file a grievance with:
Blue Shield of California
Civil Rights Coordinator
P.O. Box 629007
El Dorado Hills, CA 95762-9007
Phone: (844) 831-4133 (TTY: 711)
Fax: (844) 696-6070
Email: BlueShieldCivilRightsCoordinator@blueshieldca.com
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our
Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the
U.S. Department of Health and Human Services, Office for Civil Rights electronically through the
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
(800) 368-1019; TTY: (800) 537-7697
Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
Blue Shield of California
601 12
th
Street, Oakland CA 94607
Blue Shield of California is an independent member of the Blue Shield Association
A20275 (12/19)
blueshieldca.com
Notice of the Availability of Language Assistance Services
Blue Shield of California
IMPORTANT: Can you read this letter? If not, we can have somebody help you read it.
You may also be able to get this letter written in your language. For help at no cost, please
call right away at the Member/Customer Service telephone number on the back of your
Blue Shield ID card, or (866) 346-7198.
IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla.
También puede recibir esta carta en su idioma. Para ayuda sin cargo, por favor llame
inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de
su tarjeta de identificación de Blue Shield o al (866) 346-7198. (Spanish)
重要通知:您能讀懂這封信嗎?如果不能,我們可以請人幫您閱讀。這封信也可以 用您所講的語言書寫。
如需免费幫助,請立即撥打登列在您的Blue Shield ID背面上的 會員/客戶服務部的電話,或者撥打
電話 (866) 346-7198(Chinese)
QUAN TRNG: Quý v có th đọc lá thư này không? Nếu không, chúng tôi có th nh ngưi giúp quý
v đọc thư. Quý v cũng có th nhn lá thư này đưc viết bng ngôn ng ca quý v. Đ đưc h tr
min phí, vui lòng gi ngay đến Ban Dch v Hi viên/Khách hàng theo s mt sau th ID Blue Shield
ca quý v hoc theo s (866) 346-7198. (Vietnamese)
MAHALAGA: Nababasa mo ba ang sulat na ito? Kung hindi, maari kaming kumuha ng
isang tao upang matulungan ka upang mabasa ito. Maari ka ring makakuha ng sulat na
ito na nakasulat sa iyong wika. Para sa libreng tulong, mangyaring tumawag kaagad sa
numerong telepono ng Miyembro/Customer Service sa likod ng iyong Blue Shield ID kard,
o (866) 346-7198. (Tagalog)
Baa’ ákohwiindzindoo7g7: D77 naaltsoos7sh y77niłta’go b77n7ghah? Doo b77n7ghahgóó é7, naaltsoos nich’8’
yiid0o[tah7g77 ła’ nihee hól=. D77 naaltsoos a[d0’ t’11 Din4 k’ehj7 1dooln77[ n7n7zingo b7ighah. Doo b22h 7l7n7g0
sh7k1’ adoowo[ n7n7zing0 nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 Blue Shield bee n47ho’d7lzin7g7
bine’d44’ bik11’ 47 doodag0 47 (866) 346-7198 j8’ hod77lnih. (Navajo)
중요: 서신을 읽을 있으세요? 읽으실 경우, 도움을 드릴 있는 사람이 있습니다. 또한 다른
언어로 작성된 서신을 받으실 수도 있습니다. 무료로 도움을 받으시려면 Blue Shield ID 카드 뒷면의
회원/고객 서비스 전화번호 또는 (866) 346-7198 지금 전환하세요. (Korean)
Կ
ԿԱԱՐՐԵԵՎՎՈՈՐՐ ԷԷ Կարողանում ե՞ք կարդալ այս նամակը։ Եթե ոչ, ապա մենք կօգնենք ձեզ։ Դուք պետք է
նաև կարողանաք ստանալ այս նամակը ձեր լեզվով։ Ծառայությունն անվճար է։ Խնդրում ենք
անմիջապես զանգահարել Հաճախորդների սպասարկման բաժնի հեռախոսահամարով, որը նշված է
ձեր Blue Shield ID քարտի ետևի մասում, կամ (866) 346-7198 համարով։ (Armenian)
ВАЖНО:
Не можете прочесть данное письмо? Мы поможем вам, если необходимо. Вы также можете
получить это письмо написанное на вашем родном языке. Позвоните в Службу клиентской/членской
поддержки прямо сейчас по телефону, указанному сзади идентификационной карты Blue Shield, или
по телефону (866) 346-7198, и вам помогут совершенно бесплатно. (Russian)
お客様は、この手紙を読むことができますか? もし読むことができない場合、弊社が、お客様
をサポートする人物を手配いたします。 また、お客様の母国語で書かれた手紙をお送りすることも
能です。 無料のサポートを希望される場合は、Blue Shield IDカードの裏面に記載されている会員/お客
様サービスの電話番号、または(866) 346-7198にお電話をおかけください。 (Japanese)
blueshieldca.com
:ﻢﮭﻣ ﯽﻣ ﺎﯾآﯽﻣ ،ﺖﺳا ﯽﻔﻨﻣ نﺎﺘﺨﺳﺎﭘ ﺮﮔا ؟ﺪﯿﻧاﻮﺨﺑ ار ﮫﻣﺎﻧ ﻦﯾا ﺪﯿﻧاﻮﺗﯽﻣ ﯽﺘﺣ .ﻢﯿھد راﺮﻗ نﺎﺗرﺎﯿﺘﺧا رد ﺎﻤﺷ ﮫﺑ ﮏﻤﮐ یاﺮﺑ ار ﯽﺴﮐ ﻢﯿﻧاﻮﺗ ﮫﺨﺴﻧ ﺪﯿﻧاﻮﺗ
زا ﺖﻗو تﻮﻓ نوﺪﺑ
ً
ﺎﻔﻄﻟ ،نﺎﮕﯾار ﮏﻤﮐ ﺖﻓﺎﯾرد یاﺮﺑ .ﺪﯿﻨﮐ ﺖﻓﺎﯾرد نﺎﺗدﻮﺧ نﺎﺑز ﮫﺑ ار ﮫﻣﺎﻧ ﻦﯾا بﻮﺘﮑﻣ ﯽﺳﺎﻨﺷ ترﺎﮐ ﺖﺸﭘ رد ﮫﮐ ﯽﻨﻔﻠﺗ هرﺎﻤﺷ ﻖﯾﺮط
Blue Shield ﻦﻔﻠﺗ هرﺎﻤﺷ ﻖﯾﺮط زا ﺎﯾ و ﺖﺳا هﺪﺷ جرد نﺎﺗ7198-346 )866.ﺪﯾﺮﯿﮕﺑ سﺎﻤﺗ یﺮﺘﺸﻣ/ﺎﻀﻋا تﺎﻣﺪﺧ ﺎﺑ ( (Persian)
:        ?               
                     
Blue Shield ID     /    ,  (866) 346-7198    (Punjabi)
 ?   
  
 /  Blue Shield
  (866) 346-7198 (Khmer)
: ﻢﮭﻤﻟا اﺬھ ﻰﻠﻋ لﻮﺼﺤﻟا ﻰﻟإ
ً
ﺎﻀﯾأ جﺎﺘﺤﺗ ﺪﻗ .ﮫﺗءاﺮﻗ ﻲﻓ كﺪﻋﺎﺴﯿﻟ ﺎﻣ ﺺﺨﺷ رﺎﻀﺣإ ﺎﻨﻨﻜﻤﯾ ،ﮫﺗءاﺮﻗ ﻊﻄﺘﺴﺗ ﻢﻟ نأ ؟بﺎﻄﺨﻟا اﺬھ ةءاﺮﻗ ﻊﯿﻄﺘﺴﺗ ﻞھ
ﺎﺠﻟا ﻰﻠﻋ نوﺪﻤﻟا ءﺎﻀﻋﻷا ﺪﺣأ/ءﻼﻤﻌﻟا ﺔﻣﺪﺧ ﻒﺗﺎھ ﻢﻗر ﻰﻠﻋ نﻵا لﺎﺼﺗﻻا ﻰﺟﺮﯾ ،ﺔﻔﻠﻜﺗ نوﺪﺑ ةﺪﻋﺎﺴﻤﻟا ﻰﻠﻋ لﻮﺼﺤﻠﻟ .ﻚﺘﻐﻠﺑ
ً
ﺎﺑﻮﺘﻜﻣ بﺎﻄﺨﻟا ﻲﻔﻠﺨﻟا ﺐﻧ
ﺔﯾﻮﮭﻟا ﺔﻗﺎﻄﺑ ﻦﻣBlue Shield ﻢﻗﺮﻟا ﻰﻠﻋ وأ7198-346 )866.((Arabic)
TSEEM CEEB: Koj pos tuaj yeem nyeem tau tsab ntawv no? Yog hais tias nyeem tsis tau, peb tuaj yeem nrhiav ib tug
neeg los pab nyeem nws rau koj. Tej zaum koj kuj yuav tau txais muab tsab ntawv no sau ua koj hom lus. Rau kev pab
txhais dawb, thov hu kiag rau tus xov tooj Kev Pab Cuam Tub Koom Xeeb/Tub Lag Luam uas nyob rau sab nraum nrob
qaum ntawm koj daim npav Blue Shield ID, los yog hu rau tus xov tooj (866) 346-7198. (Hmong)
สําคญ: 


 
 Blue Shield 
(866) 346-7198 (Thai)
महवप
ण:       
?  ,    
        

     
   
:
       Blue Shield ID 
   
/   ,  (866) 346-7198   
(Hindi)
:
ານສາມາດ
ານ
ດໝາຍນ
ໄດ
?
າອ
ານບ
ໄດ
, ພວກເຮ
ສາມາດໃຫ
ບາງຄ
ນຊ
ວຍ
ານໃຫ
ານ
ໄດ
.
ານຍ
ສາມາດ
ໃຫ
ແປ
ດໝາຍນ
ເປ
ນພາສາຂອງ
ານໄດ
.
າລ
ຄວາມຊ
ວຍເຫ
ອແບບ
ເສຍ
, ກະ
ນາ
ໂທຫາເບ
ໂທຂອງຝ
າຍ
ການສະມາ
/
ກຄ
ໃນທ
ນທ
ເບ
ໂທລະ
ບຢ
ານ
ງບ
ດສະມາ
Blue Shield ຂອງທ
ານ,
ໂທໄປຫາເບ
(866) 346-7198. (Laotian)
blueshieldca.com
Notice of the Availability of Language Assistance Services
Blue Shield of California Life & Health Insurance Company
No Cost Language Services. You can get an interpreter. You can get documents read to you
and some sent to you in your language. For help, call us at the number listed on your ID card or
1-866-346-7198. For more help call the CA Dept. of Insurance at 1-800-927-4357.
English
Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le
envíen algunos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de
identificación o al 1-866-346-7198. Para obtener más ayuda, llame al Departamento de Seguros de
CA al 1-800-927-4357.
Spanish
。您可獲得口譯員服務。可以用中文把文件唸給您聽有些文件有中文的版也可以把這些文
件寄給您。欲取得協助,請致電您的保險卡所列的電話號碼,或撥打
1-866-346-7198
與我們聯絡。欲取得其他
協助,請致電
1-800-927-4357
與加州保險部聯絡。
Chinese
Các Dch V Tr Giúp Ngôn Ng Min Phí. Quý v có th đưc nhn dch v thông dch. Quý v có th đưc
ngưi khác đc giúp các tài liu và nhn mt s tài liu bng tiếng Vit. Đ đưc giúp đ, hãy gi cho chúng tôi
ti s đin thoi ghi trên th hi viên ca quý v hoc 1-866-346-7198. Đ đưc tr giúp thêm, xin gi S Bo
Him California ti s 1-800-927-4357.
Vietnamese
무료
통역
서비스
.
귀하는
한국어
통역
서비스를
받으실
있으며
한국어로
서류를
낭독해주는
서비스를
받으실
있습니다
.
도움이
필요하신
분은
귀하의
ID
카드에
나와있는
안내
전화
: 1-866-346-7198
번으로
문의해
주십시오
.
보다
자세한
사항을
문의하실
분은
캘리포니아
보험국
,
안내
전화
1-800-927-4357
번으로
연락해
주십시오
.
Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at
maipababasa mo sa Tagalog ang mga dokumento. Para makakuha ng tulong, tawagan kami sa
numerong nakalista sa iyong ID card o sa 1-866-346-7198. Para sa karagdagang tulong, tawagan
ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
Անվճար
Լեզվական
Ծառայություններ։
Դուք
կարող
եք
թարգման
ձեռք
բերել
և
փաստաթղթերը
ընթերցել
տալ
ձեզ
համար
հայերեն
լեզվով։
Օգնության
համար
մեզ
զանգահարեք
ձեր
ինքնության
(ID)
տոմսի
վրա
նշված
կամ
1-866-346-7198
համարով։
Լրացուցիչ
օգնության
համար
1-800-927-4357
համարով
զանգահարեք
Կալիֆորնիայի
Ապահովագրության
Բաժանմունք։
Armenian
Беслпатные услуги перевода. Вы можете воспользоваться услугами переводчика, и ваши
документы прочтут для вас на русском языке. Если вам требуется помощь, звоните нам по
номеру, указанному на вашей идентификационной карте, или 1-866-346-7198. Если вам
требуется дополнительная помощь, звоните в Департамент страхования штата Калифорния
(Department of Insurance), по телефону 1-800-927-4357.
Russian
日本語で通訳をご提供し、書類をお読みします。サービスをご希望の方は、IDカー
ド記載の番号または
1-866-346-7198
までお問い合わせください。更なるお問い合わせは、カリフォルニア州
保険庁、
1-800-927-4357
までご連絡ください
Japanese
تﺎﻣﺪﻧﺎﺠﻣ نﺎﺑز ﮫﺑ طﻮﺑﺮﻣ. ﺪﻧﻮﺷ هﺪﻧاﻮﺧ نﺎﺘﯾاﺮﺑ ﯽﺳرﺎﻓ نﺎﺑز ﮫﺑ کراﺪﻣ ﺪﯿﺋﻮﮕﺑ و ﺪﯿﻨﮐ هدﺎﻔﺘﺳا ﯽھﺎﻔﺷ ﻢﺟﺮﺘﻣ ﮏﯾ تﺎﻣﺪﺧ زا ﺪﯿﻧاﻮﺘﯿﻣ. ی ا
هرﺎﻤﺷ ﻦﯾا ﺎﯾ و ﺖﺳا هﺪﺷ ﺪﯿﻗ ﺎﻤﺷ ﯽﺋﺎﺳﺎﻨﺷ ترﺎﮐ یور ﮫﮐ ﯽﻨﻔﻠﺗ هرﺎﻤﺷ ﻖﯾﺮط زا ﺎﻣ ﺎﺑ،ﮏﻤﮐ ﺖﻓﺎﯾرد1-866-346-7198 ﺪﯾﺮﯿﮕﺑ سﺎﻤﺗ. یاﺮﺑ
ﮫﺑ ،ﺮﺘﺸﯿﺑ ﮏﻤﮐ ﺖﻓﺎﯾردCA Dept. of Insurance ) ﺎﯿﻧﺮﻔﯿﻟﺎﮐ ﮫﻤﯿﺑ هرادا ( هرﺎﻤﺷ ﮫﺑ1-800-927-4357 ﺪﯿﻨﮐ ﻦﻔﻠﺗ.Persian
blueshieldca.com
ਮੁਫ਼ਤ
ਭਾਸ਼ਾ
ਸੇਵਾਵਾਂ
:





























(ID)

'



'


1-866-346-7198 '

'











1-800-927-4357 '



Punjabi





    

1-866-346-7198

   

1-800-927-4357
Khmer
ﺔﻘﻠﻜﺗ نوﺪﺑ ﺔﻤﺟﺮﺗ تﺎﻣﺪﺧ. ﻐﻠﻟﺎﺑ ﻚﻟ ﻖﺋﺎﺛﻮﻟا ةءاﺮﻗ و ﻢﺟﺮﺘﻣ ﻲﻠﻋ لﻮﺼﺤﻟا ﻚﻨﻜﻤﯾﺔﯿﺑﺮﻌﻟا ﺔ . ﻞﺼﺗا ،ةﺪﻋﺎﺴﻤﻟا ﻲﻠﻋ لﻮﺼﺤﻠﻟ
ﻢﻗﺮﻟا ﻲﻠﻋ وأ ﻚﺘﯾﻮﻀﻋ ﺔﻗﺎﻄﺑ ﻲﻠﻋ ﻦﯿﺒﻤﻟا ﻢﻗﺮﻟا ﻲﻠﻋ ﺎﻨﺑ1-866-346-7198 . ،تﺎﻣﻮﻠﻌﻤﻟا ﻦﻣ ﺪﯾﺰﻤﻟا ﻲﻠﻋ لﻮﺼﺤﻠﻟ
ﻢﻗﺮﻟا ﻲﻠﻋ ﺎﯿﻧرﻮﻔﯿﻟﺎﻛ ﺔﯾﻻﻮﻟ ﻦﯿﻣﺄﺘﻟا ةرادﺈﺑ ﻞﺼﺗا1-800-927-4357.
Arabic
Cov Kev Pab Txhais Lus Tsis Them Nqi. Koj yuav thov tau kom muaj neeg los txhais lus rau koj thiab kom
neeg nyeem cov ntawv ua lus Hmoob. Yog xav tau kev pab, hu rau peb ntawm tus xov tooj nyob
hauv koj daim yuaj ID los sis 1-866-346-7198. Yog xav tau kev pab ntxiv hu rau CA lub Caj Meem Fai
Muab Kev Tuav Pov Hwm ntawm 1-800-927-4357
Hmong
 










1-866-346-7198



 

1-800-927-4357
Thai


































,

ID






,

1-866-346-7198











(CA Dept. of Insurance)

1-800-927-4357



Hindi
Doo b11h 7l7n7g0 saad bee y1t’i’ bee an1’1wo’. D77 sh1 ata’halne’doo7g7 h0l=-doo n7n7zingo 47 b7ighah. Naaltsoos
naanin1h1jeeh7g7 shich’8’ y7idooltah 47 doodag0 [a’ shich’8’ 1dooln77[ n7n7zingo b7ighah. Sh7k1 a’doowo[ n7n7zingo
nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 ninaaltsoos doot[‘7zh7g7 bee n47ho’d7lzin7g7 bine’d44’ bik11’ 47 doodag0
47 (866)346-7198j8’ hod77lnih. H0zh= sh7k1 an11’doowo[ n7n7zingo 47 d77 b4eso 1ch’22h naa’nil bi[ haz’32j8’
1-800-927-4357j8 hod77lnih.
Navajo
.
ານສາມາດ
ເອ
າຜ
ແປພາສາໄດ
.
ານສາມາດ
ໃຫ
ານເອກະສານໃຫ
ານ
ແລະ
ເອກະສານບາງ
າງ
ເປ
ນພາສາຂອງທ
ານ.
າລ
ຄວາມຊ
ວຍເຫ
, ໃຫ
ໂທຫາພວກເຮ
ຕາມເບ
ໂທລະ
ບທ
ໃນ
ປະ
າຕ
ຂອງ
ານ
ໂທຫາເບ
1-866-346-7198.
າລ
ຄວາມ
ວຍເຫ
ເພ
ເຕ
ມໂທຫາ ພະແນກ ປະ
ໄພຂອງ
ດຄາລ
ເນໄດ
ເບ
1-800-927-4357.
Laotian