- Broker census (PDF) — Use this form for new and renewing groups. (Updated 5/1/20)
- Broker of Record Authorization (New Group) (PDF) — If you submit new groups for coverage using our self-service tool, your clients must complete this form authorizing you to apply online for coverage on their behalf. Completed forms are uploaded as part of the online submission process.
- Declination of Coverage (PDF) — Your clients’ eligible employees can use this form to decline Kaiser Permanente coverage. Or your clients can use the “Employer Attestation Declination of Coverage” form found below to list eligible employees who have declined coverage. (English — updated 5/1/20)
- Declination of Coverage (PDF) (Spanish — updated 5/20/20)
- Declination of Coverage (PDF) (Chinese — updated 5/20/20)
- Declination of Coverage (PDF) (Vietnamese – updated 11/2/20)
- Employer Application – 2021 (PDF) — Your clients can use this form to enroll with a 2021 effective date. (Updated 9/15/20)
- Employer Application – 2020 (PDF) — Your clients have the option of using this form or the New Group Application (below) to enroll with a 2020 effective date. (Updated 7/13/20)
- Employer Attestation Declination of Coverage (PDF) — Your clients can use this form to list eligible employees who have declined coverage. (Updated 5/1/20)
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Employee Enrollment (PDF) — Your clients’ employees can use this form to enroll with Kaiser Permanente. (English — updated 5/1/20)
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) (Spanish — updated 5/20/20)
- Employee Enrollment (PDF) (Chinese — updated 5/20/20)
- Employee Enrollment (PDF) (Vietnamese – updated 1/13/21)
- Electronic Transfer for Payment (PDF) — Your clients can use this form to authorize their first month’s payment by electronic transfer. (Updated 5/1/20)
- New Employee Eligibility (PDF) — Your clients can use this form to document new eligible employees hired in the previous 30 calendar days. (Updated 5/1/20)
- New Group Application — 2020 (PDF) — Your clients can use the New Group Application to enroll with a 2020 effective date. (Updated 9/27/19)
- Owner/Officer Eligibility Statement (PDF) — Your clients can use this form to provide proof of eligibility for proprietors, partners, and corporate officers not appearing on their DE-9C form. (Updated 9/27/19)
- Payroll attestation (PDF) — Your clients can use this form if they're a new business (start-up, breakaway or establishing payroll from an existing business) and don't have payroll to document eligible employees.
5/1/20
- Contact Change Request (PDF) — Your clients can use this form to change their billing contact, interested party contact, or contract signer information. (Updated 5/1/20)
- Customer Address or Name Change Request (PDF) — Your clients can use this form to change their company address, name, or federal tax ID (EIN) number. (Updated 5/1/20)
- Employee/Dependent Change (PDF) — Your clients’ employees can use this form to add or remove dependents from their accounts, change addresses, or change names. (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)
- Employee Enrollment (PDF) — Your clients’ employees can use this form to enroll with Kaiser Permanente. (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 11/2/20)
- Employer Attestation for COBRA/CAL-COBRA & TEFRA Status (PDF) — Use this form to let us know if you have a COBRA status change from Cal-COBRA to Federal COBRA or Federal COBRA to Cal-COBRA. Write in the effective date of change on the form. (Updated 9/15/20)
- Federal COBRA application (PDF) — For groups with 20+ eligible employees, use the Federal COBRA application to cover your client’s former employees and their dependents. For groups with 2–19 eligible employees, your client’s former employees must contact the Kaiser Permanente Member Service Contact Center at 1-800-464-4000 for enrollment assistance.
- Group Termination Request form — To receive this form, please contact your assigned Account Manager. If you don’t have an assigned Account Manager, contact the Small Business Customer Connection Team. For more information, please see our small business service tip on “Terminating a small group contract”.
- HIPAA Authorization (PDF) — Your clients can use this form to authorize use and/or disclosure of patient health information. (English — updated 8/5/16)
- New Group Application — 2019 (PDF) — Use this 2019 version of the New Group Application to help groups with 2019 effective dates add a PPO plan. (Updated 10/2/18)
- Primary Administrator Online Access Request (PDF) — Your clients can use this form to request access to our secure online account services and set up automatic payments for the second month onward. (Updated 9/27/19)
- Participation and contribution attestation (PDF) — Your client must complete this form to attest that their company continues to meet the minimum participation and contribution requirements for small business coverage. (Updated 9/27/19)
- Payroll attestation (PDF) — Your clients can use this form if they're a new business (start-up, breakaway or establishing payroll from an existing business) and don't have payroll to document eligible employees.
- Plan Add/Change Request — 2021 (PDF) — Groups that have already renewed and wish to add or discontinue plans should use this form to request a midyear plan change prior to their next renewal. (Updated 10/1/20) Fax changes to 800-369-8010 or email them to amt@kp.org. For changes to take place that month, we must receive them by 5 p.m. on the 15th of the month. Otherwise the changes will take place the following month.
- Plan Add/Change Request — 2020 (PDF) — Groups that have already renewed and wish to add or discontinue plans should use this form to request a midyear plan change prior to their next renewal. (Updated 9/27/19) Fax changes to 800-369-8010 or email them to amt@kp.org. For changes to take place that month, we must receive them by 5 p.m. on the 15th of the month. Otherwise the changes will take place the following month.
- Plan Add/Change Request — 2019 (PDF) — Groups that have already renewed and wish to add or discontinue plans should use this form to request a midyear plan change prior to their next renewal. (Updated 10/2/18) Fax changes to 800-369-8010 or email them to amt@kp.org. For changes to take place that month, we must receive them by 5 p.m. on the 15th of the month. Otherwise the changes will take place the following month.
- Subscriber Termination and Transfer (PDF) — Your clients can use this form to terminate an employee’s coverage or transfer an employee to a different enrollment unit. (Updated 9/27/19)
Small Business Change of Ownership
If you’re looking for a Small Business Change of Ownership form, please call our Small Business Services Customer Connection Team at 800-790-4661, option 3.
