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Business name (please print):
17 AGREEMENT AND SIGNATURE
As a company principal/corporate officer, having authority to contract with KFHP and KPIC, I agree that:
• Prepaid monthly premiums will be posted to Kaiser Permanente’s account by the due date on the Kaiser Permanente billing statement.
• My company will use employee enrollment application forms provided or approved by KFHP and KPIC for new employees.
• The eligibility data provided by my company to Kaiser Permanente will include coverage effective dates for my company’s employees that correctly
account for eligibility in compliance with the waiting period requirement in the Affordable Care Act and federal regulations, which require that
waiting periods not exceed 90 days. My company acknowledges that the effective date of coverage for new employees and their eligible family
dependents will be on the 1st of the month and won’t exceed the waiting period established by my company.
• My company will abide by the contract provisions.
I have read, understood, and agreed to Kaiser Permanente’s Small Business Guidelines, which may be included with my rate quote or, if not included,
is available at kp.org/smallbusinessguidelines/ca.
I attest that my company meets the definition of “small employer” as defined by applicable federal and state law. I have a minimum of 1 W-2
employee (excluding the owner, spouse, or legal domestic partner) and I will comply with the health plan’s participation requirement.
I attest that my company isn’t participating in a large group trust and agree not to participate while enrolled under Kaiser Permanente small
business coverage.
I understand that a Summary of Benefits and Coverage (SBC) for each of my medical plans is available at kp.org/smallbusiness-sbc/ca. I agree
to provide my eligible employees with SBCs for any plan(s) I have chosen or change to in the future.
I certify, to the best of my knowledge, that all of the responses given are true, correct, and complete. I understand that if I performed an act or
practice constituting fraud or made an intentional misrepresentation of material fact, any coverage approved by KFHP or KPIC may be canceled or
the applicable premiums/rates may be adjusted.
I understand that if KFHP or KPIC intends to rescind or terminate my coverage, I’ll be sent a notice via regular certified mail at least 30 days prior to
the effective date of the rescission or termination explaining the reasons for the intended rescission or termination and notifying me of my right to
appeal that decision to the Department of Managed Health Care director or the Department of Insurance commissioner. I understand that after 24
months following the issuance of my KFHP health plan contract/KPIC health insurance policy, KFHP/KPIC shall not rescind my plan contract/policy
for any reason, and shall not cancel my plan contract/policy, limit any of the provisions of my plan contract/policy, or raise premiums on my plan
contract/policy due to any omissions, misrepresentations, or inaccuracies in the application form, whether willful or not.
KAISER FOUNDATION HEALTH PLAN, INC., ARBITRATION AGREEMENT*
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure
regulation, and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my
heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), 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 KFHP, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or
unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery
of, services or items, 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 contained in the Evidence of Coverage.
Authorized company signer (please print name) Company title (please print)
Signature required for all Kaiser Permanente Plans
X
Date
* Disputes arising from the following fully insured Kaiser Permanente Insurance Company coverages aren’t subject to binding arbitration: 1) the
Preferred Provider Organization (PPO) and the Out-of-Network portion of the Point-of-Service (POS) plans; 2) Preferred Provider Organization
(PPO) plans; 3) Out-of-Area Indemnity (OOA) plans; and 4) KPIC Dental plans.
California Small Group
EMPLOYER APPLICATION
KFHP-KPIC-APP-CA-8-2021
Small Group 633439848 August 2021 ADA
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