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Page 1 of 2
Small Business
771851127 January 2022 Broker
Small Business
CENSUS
INSTRUCTIONS
For a no-obligation rate quote, complete the form below and email to kaiser.sbu.sales@kp.org. Please list all employees who are eligible for
health care benets.
COMPANY INFORMATION
Company name
Street address (no P.O. boxes)
City State ZIP County
Office phone
( ) –
Ext. Fax
( ) –
Number of employees who are eligible for health coverage
Current carrier
(continues on page 2)
BROKER INFORMATION
Firm name Kaiser Permanente firm ID
Agent name Agency license #
Office phone
( ) –
Ext. Fax
( ) –
Cell phone
( ) –
Email
Street address City
State ZIP
STRATEGY (OPTIONAL)
Sole Carrier Slice Multiple Plan Offering Account-Based Plans Workforce Health
EMPLOYEE/DEPENDENT ELIGIBILITY INFORMATION*
List all employees, owners, and dependents you’d like quoted. A dependent is a spouse, domestic partner, child or domestic partner’s child.
Use additional page, as needed.
*For each employee/dependent listed, all elds must be lled out completely to process this form.
First name Last name or initial Date of birth
(mm/dd/yyyy)
or age
Home ZIP Relationship (check one)
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
CONTACT INFORMATION
For more information, please contact Kaiser Permanente at 800-789-4661, option 2.
Small Business
CENSUS
EMPLOYEE/DEPENDENT ELIGIBILITY INFORMATION* (continued from page 1)
Company name
*For each employee/dependent listed, all elds must be lled out completely to process this form.
First name Last name or initial Date of birth
(mm/dd/yyyy)
or age
Home ZIP Relationship (check one)
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Employee/owner Spouse Child
Small Business
771851127 January 2022 Broker ADA
Page 2 of 2
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Completed 2 November 2021

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