Small Business
373272042 January 2020
ADA
Small Business
PAYROLL ATTESTATION
IMPORTANT INFORMATION
Please complete this form if you’re a new business (start-up, breakaway or establishing payroll from an existing business) and don’t have payroll, to
document eligible employees.
1 COMPANY INFORMATION
Company name Group ID (if assigned)
Check one: Start-up
Breakaway from an existing business
Existing business with newly established payroll
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 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. I will provide the company’s rst 30 days
complete payroll records for all employees within 45 days of the effective date. I understand that Kaiser Permanente reserves the right to not renew
coverage for my group if it doesn’t meet Kaiser Permanente criteria as outlined in the Group Agreement and/or Group Contract.
Authorized company signer (please print name) Company title (please print)
Signature Date
X
click to sign
signature
click to edit
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