ACTIVE Enrollment / Change Forms

Choose the applicable Enrollment / Change Form for the Health Plan selection you are choosing.


For Kaiser Permanente and Blue Shield of California HMO Plans, there are limited coverage service areas within Northern California.

Blue Shield of California Plans are not available to all Classifications. Refer to your Summary Plan Description for details.

Back to main Health and Welfare page

Blue Shield of California PPO and HMO Active Enrollment / Change Form
Kaiser Permanente HMO Active Enrollment / Change Form

To view PDF files you will need the free Adobe™ Acrobat Reader®
Terms of Use | Privacy Statement
This site is best viewed with Internet Explorer 9.0 or higher, Firefox 1.5 or higher, Safari 2.0 or higher.