Signature of Applicant (or financially-responsible party if Applicant is under the age of 18)
Date (mm/dd/yyyy)
Print Name
COVERED CALIFORNIA binding arbitration agreement
STEP 3
Signature of Applicant Date (mm/dd/yyyy)
Read & sign this application.
STEP 5
• 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.
• I know that my information on this form will only be used to determine eligibility for health coverage and will be kept private as
required by law. If I’m eligible, it will be used to help me enroll.
• I know that I must tell Covered California for Small Business if anything changes from what I wrote on this application. I can call my
employer, my employer’s Covered California Certified Insurance Agent or call (877) 453-9198 to report changes.
• I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation,
gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file.
Page 3 of 5
NEED HELP WITH YOUR APPLICATION? Contact your employer or your employer’s Covered California
Certified Insurance Agent with questions, visit CoveredCA.com/ForSmallBusiness or call us at
(855) 777-6782. Para obtener una copia de este formulario en Español, llame (855) 777-6782.
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.
continued on next page ➡
Covered California for Small Business Employee Application | Rev. 3/17/2021
I did not use a Certified Insurance Agent.
The applicant completed and executed this application, and I assisted the applicant by offering advice in providing
responses to questions. I advised the applicant that he/she should answer all such questions completely and
truthfully and that no information requested should be withheld. I explained to the applicant, in easy-to-under-
stand language, the risk to the applicant of providing inaccurate information and the applicant understood the
explanation. To the best of my knowledge, based on what the applicant disclosed to me, the information in this
application is accurate and complete. I understand that if any portion of this statement signed by me is false,
I may be subject to civil penalties of up to $10,000 as authorized under California Health and Safety Code
Section 1389.8 and Insurance Code Section 10119.3.
STEP 4
If a Certified Insurance Agent helped you complete this
application, please obtain their signature below.
Signature of Certified Insurance Agent
Print Name Date
Employer ____________________________________________________________________________________________________
click to sign
signature
click to edit
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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