488012023 July 2020
NEW EMPLOYEE ELIGIBILITY
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
(last 4 digits)
3 READ AND SIGN
I afrm 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 verication and agree to provide Kaiser Permanente with any information necessary to do so.
Authorized company signer (please print name) Company title (please print)
click to sign
click to edit