Administrative Forms

Administrative Guidelines

Do you have questions regarding the rules and regulations of your policy? Our administrative guidelines are a good place to go to get those questions answered.

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Cobra (for 20 or more employees)

Do you have an employee that is leaving the company and wants to keep their coverage? If so, please submit this application to us and we will extend the employee’s coverage per federal guidelines. Please note that the employee will stay on your bill, so you are responsible for billing and collecting premium for that person directly.

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Cal Cobra (California Only)

This form is used for employees who wish to continue their group coverage and have either exhausted all applicable COBRA benefits or who work for firms with less than 20 employees. When filling out this form the employee must make sure to sign and date as well as send the first six months payment. Once this form has been processed, a new account is created for the former employee and we bill them directly at their home address. Kelsey National Corporation charges a 10% fee for the administration of CAL-COBRA accounts.

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ChoicePlus Dental Claim Form (Security Life)

Only to be used for Indemnity/PPO plans.

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ChoicePlus Vision Claim Form (Security Life)

Only to be used for Indemnity/PPO plans.

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ChoicePlus Enrollment Forms

Employer enrollment form.

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Employee enrollment form. (English)

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Employee enrollment form. (Spanish)

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Renewal Period Coverage Changes

Description of allowable changes.

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