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COVERED CALIFORNIA BINDING ARBITRATION AGREEMENT
I understand that, if I select a Health Plan that uses mandatory binding arbitration to resolve disputes, I am agreeing to arbitrate claims that
relate to my or a dependent’s membership in the Health Plan (except for Small Claims Court cases and claims that cannot be subject to binding
arbitration under governing law). I understand that any dispute between myself, my heirs, relatives, or other associated parties on the one hand
and the Health Plan, any contracted health care providers, administrators, or other associated parties on the other hand for alleged violation
of any duty arising out of or related to membership in the Health Plan, including , for premises liability, relating to the coverage for, or delivery
of, services or items, or, if I select a Kaiser Permanente Health Plan, including any claim for medical or hospital malpractice (a claim that medical
services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), irrespective of legal theory, must be
decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial
review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full
arbitration provision is in the Health Plan’s coverage document, which is available for my review.
I am signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my
knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.
Employee Name Employer Name
CCSB Group #
Signature of Employee Date (mm/dd/yyyy)
Employer Name
NEED HELP WITH YOUR FORM? Contact your employer or your employer’s Covered California Certified Insurance Agent with questions, visit
CoveredCA.com or call us at (855) 777-6782. Para obtener una copia de este formulario en Español, llame (855) 777-6782.
SIGN THE FORM
Your employer will send us your form, and we will contact you if we need additional information or to let you know your request
for changes to your coverage have been approve
d.
RETURN YOUR COMPLETED, SIGNED FORM TO YOUR EMPLOYER
Signature of Employee Date (mm/dd/yyyy)
Employer Name
I acknowledge that the coverage available to me has been explained to me by my employer and I have the right to enroll
in the coverage oered. I have voluntarily decided not to enroll myself and/or my eligible dependent(s). By declining this
coverage I acknowledge that I and/or my eligible dependents will have to wait until my employer’s next open enrollment
period to enroll or change coverage, unless eligible for a special enrollment period through a qualifying event.
DECLINATION ACKNOWLEDGEMENT
CERTIFIED INSURANCE AGENT INFORMATION
Certified Insurance Agent Name Email Phone Number
Please tell us the Certied Insurance Agent who assisted you with your Covered California for Small Business health coverage.
I did not receive assistance from a Certied Insurance Agent.
Covered California for Small Business Change Request Form for Employees | Version CCSB V3.102219 2020-Q1
STOP! ONLY complete and sign below if you are declining coverage.
!
I am declining medical coverage for (check all that apply):
Self
Spouse / Domestic Partner
Child(ren) Name(s)
Reason for declining coverage (choose one):
m
Covered by spouse’s / domestic partner’s group plan
m
Covered by individual policy
m
Covered by Tricare
m
Covered by Medicare
m
Covered by Medi-Cal
m
Covered by Other:
m
Coverage is too expensive. (You may want to contact Covered CA at
www.coveredca.com for help in understanding the available options
andnancialassistanceintheCoveredCaIndividualMarketplace)
I am declining dental coverage for (check all that apply):
Self
Spouse / Domestic Partner
Child(ren) Name(s)
