474902074 July 2020
DECLINATION OF COVERAGE
Employees and owners: Please use this form only to decline group health coverage.
Employers: Keep a copy of this form for your records. Ensure name of carrier field is completed to avoid processing delays. If you’d like to
terminate a subscriber, please use the Subscriber Termination/Transfer Form.
1 COMPANY INFORMATION
Company name Group ID (if assigned)
2 REASON FOR DECLINING
I’ve been offered Kaiser Permanente group health coverage by my employer. I voluntarily choose not to enroll myself in a Kaiser Permanente plan
at this time. I understand that the next opportunity to enroll will be during the annual open enrollment period or after a qualifying event.
Declination reason and carrier name impact the participation requirement. Only group coverage counts toward the participation requirement.
Reason for declining (check one):
I’m covered by another employer’s health plan through my spouse/domestic partner/parent.
I’m covered by another health plan offered by this employer.
I’m covered by another employer I work for.
I’m covered by group coverage through COBRA or Cal-COBRA.
I’m covered by Medicare, Medi-Cal, or Tricare (military or VA benefits).
I’m covered by an individual health plan.
Not interested in enrolling at this time.
3 READ AND SIGN
If you decline coverage for yourself, you’re also declining coverage for your eligible dependent(s). You can only enroll or change your coverage
during annual open enrollment period established by your employer or during a special enrollment period if you’ve experienced a qualifying event.
You must request coverage within 60 days of a qualifying event. Special enrollment qualifying events include:
Increase in your hours so that you meet your employer’s requirement for medical plan eligibility
Return from a leave of absence
Involuntary termination or loss of other group coverage
A dependent loses coverage elsewhere
Marriage or addition of a domestic partner
Birth, adoption of a child, or placement for adoption
Death of a spouse, domestic partner, or dependent
Employee name (please print)
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