Small Business
488010504-B July
2020
Page 2 of 3
See instructions on page 1 before completing this form. Make a copy for your records.
Small Business
EMPLOYEE ENROLLMENT
1 TO BE COMPLETED BY EMPLOYER
Company name* Group ID (if assigned) Effective date* (can only start the first of the month)
/ 01 /
Plan selection Subgroup ID (if assigned)* Employee classification (if applicable)
Enrollment reason (Please check one)
New group account Open enrollment Other:
If you have an existing account, please email completed form to csc-sd-sba@kp.org as a PDF attachment or fax to 855-355-5334.
2 TO BE COMPLETED BY EMPLOYEE (All fields with * are required.)
Have you ever been a member of, or received care from, Kaiser Permanente in California? Yes No
Social Security number* Former/Maiden name
Last name* First name* MI Preferred language (optional)
Home address* Apt. #
City* State* ZIP* County
Mailing address (if different from home) Apt. #
City State ZIP County
Date of birth (mm/dd/yyyy)*
/ /
Gender*
M F Undeclared
Day phone
( ) –
Evening phone
( ) –
If you decline coverage for yourself or an eligible dependent, you can only enroll during an 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:
•
Loss of health care (minimal essential) coverage, resulting from any of the following: loss of employer-sponsored coverage because you and/or your
dependent no longer meet the eligibility requirements, or your employer no longer offers coverage or stops contributing premium payments; loss of
eligibility for COBRA coverage (for a reason other than termination for cause or nonpayment of premium); your and/or your dependent’s individual,
Medi-Cal, Medicare, or other governmental coverage ends; or for any reason other than failure to pay premiums on a timely basis or situations allowing
for a rescission (fraud or intentional misrepresentation of material fact); or loss of health care coverage including, but not limited to, loss of that coverage
due to the circumstances described in Section 54.9801-6(a)(3)(i) to (iii), inclusive, of Title 26 of the Code of Federal Regulations and the circumstances
described in Section 1163 of Title 29 of the United States Code;
•
Gaining or becoming a dependent due to marriage, domestic partnership, birth, adoption, placement for adoption, or assumption of a parent-child relationship;
•
A valid state or federal court order that you or your dependent be covered;
•
Permanent relocation, such as moving to a new location and having a different choice of health plans, or being released from incarceration;
•
The prior health coverage issuer substantially violated a material provision of the health coverage contract;
•
A network provider’s participation in your and/or your dependent’s health plan ended when you and/or your dependent(s) were under active care for one of
the following conditions: an acute condition (an acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury,
or other medical problem that requires prompt medical attention and that has a limited duration); a serious chronic condition (a serious chronic condition
is a medical condition due to a disease, illness, or other medical problem or medical disorder that’s serious in nature and that persists without full cure
or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration); pregnancy; terminal illness
(a terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less); care of a newborn child
between birth and age 36 months; or performance of a surgery or other procedure that’s been recommended and documented by the provider to occur
within 180 days of the contract’s termination date or within 180 days of the effective date of coverage for a newly covered insured;
•
A member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active
duty service under Title 32 of the United States Code;
•
An individual demonstrates to the Department of Managed Health Care or Department of Insurance, as applicable, with respect to health benefit plans
offered outside the Exchange that the individual didn’t enroll in a health benefit plan during the immediately preceding enrollment period available because
the individual was misinformed that he or she was covered under minimum essential coverage.
(All fields with * are required.)
