Fillable NEW EMPLOYEE ELIGIBILITY (Dickerson Insurance Services)

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NEW EMPLOYEE ELIGIBILITY (Dickerson Insurance Services)

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Small Business
488012023 July 2020
ADA
Small Business
NEW EMPLOYEE ELIGIBILITY
IMPORTANT INFORMATION
Please complete this form to document eligible employees who are NOT on the DE 9C who:
•
Were hired in the last 45 days.
•
Can’t show or provide 2 weeks of pay.
1 COMPANY INFORMATION
Company name Group ID (if assigned)
2 EMPLOYEE INFORMATION
First name MI Last name
Start date
(mm/dd/yyyy)
Hourly wage/
Salary
Social Security
number
(last 4 digits)
3 READ AND SIGN
I afrm that I have authority to contract with Kaiser Foundation Health Plan, Inc., and Kaiser Permanente Insurance Company on behalf of the group. I
attest that the employees listed above are permanent, eligible employees working at least 20 hours per week. I understand that this information may
be subject to verication and agree to provide Kaiser Permanente with any information necessary to do so.
Authorized company signer (please print name) Company title (please print)
Signature Date
X
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NEW EMPLOYEE ELIGIBILITY (Dickerson Insurance Services)

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Completed 1 June 2021

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