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Attestation, Arbitration & Signature – read, complete & sign
Page 5 of 6Covered California for Small Business Employer Application | Eﬀective date 01/01/2020 — Rev. 9/18/19
To participate in Covered California for Small Business, you must attest to the following:
A. I understand that the information I provided on this form will only be used to determine eligibility for and to facilitate enrollment in
health coverage and will be kept private as required by federal and state law.
B. My waiting period is in compliance with 42 U.S.C. § 300gg-7, Section 10198.7(c) of the California Insurance Code, as amended by
Statutes 2013-2014, 1st Ex. Sess., ch. 1, § 7 and Section 1357.51(c) of the California Health and Safety Code, as amended by Statutes
2013-2014, 1st Ex. Sess., ch. 2, § 2, and all of my qualiﬁed employees have complied with the waiting period;
C. If my employee roster is included, I have consent from everyone I have listed on this application to include their personally
identiﬁable information, including but not limited to dates of birth, Social Security or tax identiﬁcation numbers, addresses, and
D. I know that under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation,
gender identity, disability, religion, marital status or veteran status. E.) I know that SHOP will not consider my group coverage
approved until SHOP has received 85 percent of the ﬁrst month's premium payment.
E. I know that SHOP will not consider my group coverage approved until SHOP has received 85 percent of the ﬁrst month's premium
F. I know that I must continue to make the required premium payments to continue to be an eligible employer in SHOP.
G. I know that I must inform all eligible employees of the availability of coverage and that those not electing coverage must wait one
year or experience a qualifying event to obtain coverage through my group plan if they later decide they would like to have coverage.
H. I understand that once coverage is approved by SHOP, changes to the coverage cannot be implemented after my eﬀective date
until my next annual election of coverage period, except to the extent the qualiﬁed employer exercises the right to change coverage
with the same issuer within the ﬁrst 30 days of the eﬀective date of coverage pursuant to Health and Safety Code 1357.504 (c) and
the Insurance Code Section 10753.06.5 (c).
I. I understand that health insurance coverage through the SHOP is subject to the applicable terms and conditions of the QHP issuer
contract or policy and applicable state law, which will determine the procedures, exclusions and limitations relating to the coverage
and will govern in the event of any conﬂict with SHOP or QHP issuer beneﬁts comparison, summary or other description of
J. I understand that once membership information is transmitted to the selected health plan issuers, group coverage eﬀective dates
cannot be changed nor can coverage be terminated until after the ﬁrst month of coverage.
K. I understand that the attestations in this section are subject to audit by SHOP at any time.
L. I understand that the attestations in this section must be maintained in order for my group to continue coverage through SHOP.
M. I certify that the total number of Full-Time Equivalent (FTE) employees that I have provided in box 7, page 2 of this application is true
and correct to the best of my knowledge.
¨ I have read and attest to the foregoing requirements for participation in CCSB.
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 have read and agree to the Binding Arbitration Agreement
Signature of Business Owner/Authorized Company Oﬃcer