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Forms

Resource library
Forms
- Our forms
- Small business forms
- Summary of Benefits and Coverage (SBC)
- Small business group administration forms
- Small business recertification
- Large business forms
- Employee forms
- Employer forms

Small business group administration forms

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Help avoid processing delays — make sure you submit fully completed, current versions of the forms below.

Employer Application — March 2021 (PDF) — You can use this form to enroll with a 2021 effective date. (Updated 2/15/21).

Employer Application — January 2021 (PDF) — You can use this form to enroll with a 2021 effective date. (Updated 1/27/21)

Employer Application — 2020 (PDF) — Use this form or the New Group Application (below) to enroll with a 2020 effective date. (Updated 7/13/2020)

New Group Application — 2020 (PDF) (updated 9/27/19) — Use this version if you'd like to enroll with a 2020 effective date.

Payroll attestation (PDF) — Use 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.

Avoid service delays — The signature must be under the Arbitration Agreement and not above it. If it’s not signed correctly, Small Business Accounts will not enroll the member and will need to request a new signature on the form.

Employee Enrollment (PDF) (English—updated 5/1/20)
Employee Enrollment (PDF) (Spanish—updated 5/20/20)
Employee Enrollment (PDF) (Chinese—updated 5/20/20)
Employee Enrollment (PDF) (Vietnamese – updated 1/13/21)

Employee/Dependent Change (PDF) (English—updated 9/27/19)
Employee/Dependent Change (PDF) (Spanish—updated 10/8/19)
Employee/Dependent Change (PDF) (Chinese—updated 10/8/19)
Employee/Dependent Change (PDF) (Vietnamese – updated 11/2/20)

Cal-COBRA packet information - When your employees are no longer covered, it’s easy to have Cal-COBRA packets sent directly to them. Just write “Please send Cal-COBRA packet” at the top of the Subscriber Termination and Transfer form. Be sure to confirm the correct member mailing address is on file with us prior to submitting the form.
Federal COBRA application (PDF) - For 20+ eligible employees, use the Federal COBRA application to cover former employees and their dependents. If you have 2–19 eligible employees, your former employees must contact the Kaiser Permanente Member Service Contact Center at 1-800-464-4000 for enrollment assistance.
Subscriber Termination and Transfer (PDF) (Updated 3/16/21)

Group Termination Request form — To receive this form, please contact the Small Business Customer Connection Team. For more information, please see our small business service tip on “Terminating your small group contract”.

Plan Add/Change Request — 2021 (PDF) (updated 1/27/21) — If you have already renewed and wish to add or discontinue plans, use this form to request a midyear plan change prior to your next renewal.
Plan Add/Change Request — 2020 (PDF) (updated 9/27/19) — If you have already renewed and wish to add or discontinue plans, use this form to request a midyear plan change prior to your next renewal.
Plan Add/Change Request — 2019 (PDF) (updated 10/2/18) — If you have already renewed and wish to add or discontinue plans, use this form to request a midyear plan change prior to your next renewal.

Contact Change Request (PDF) (updated 3/16/21)
Customer Address or Name Change Request (PDF) (updated 3/16/21)

Termination Form (PDF) required by CA AB2470 to be provided to the group and for the group to provide to their employees. Instructions for use and where to submit included in the form.

Kaiser Permanente

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