Small Business

Small business enrollment

Resources to support your clients for a smooth enrollment process.

Broker — new group enrollment

New Group Enrollment Checklist

Use this checklist to:

  • Ensure key documents are completed for a quick submission.
  • Learn additional enrollment tips
Underwriting Guidelines

Get information about Kaiser Permanente's approach to evaluating and offering coverage to new and existing small business accounts.

Broker — new group forms

Form Validation Tool

Help avoid processing delays — use the most current forms to complete every section and sign before you submit. Forms not listed on this tool are outdated and won't be accepted for processing.

Broker Census

Use this form for new and renewing groups.

Declination and Waiver of Coverage Forms

  • Submit a Declination of Coverage form to list all eligible subscribers who have declined Kaiser Permanente coverage.

    Declination of Coverage
    English (PDF) | Español (PDF) | 中文 (PDF) | Tiếng Việt (PDF)

  • Waiver of Coverage. Your clients' eligible employees can use this form to decline Kaiser Permanente coverage and return to their employer. This form is only for employer records and doesn't need to be submitted to Kaiser Permanente. Employers can use this form to transfer employee information to the Declination of Coverage form.

    Waiver of Coverage
    English (PDF) | Español (PDF) | 中文 (PDF) | Tiếng Việt (PDF)
Broker of Record Authorization (New Group)

Your clients must complete this form to grant authorization for you to apply online for coverage on their behalf. Completed forms are uploaded as part of the online submission process.

Employer Application – 2022

Use this form to enroll with a 2022 effective date.

Employer Application - 2021

Use this form to enroll with a 2021 effective date.

Employee Enrollment

Your clients’ employees can use this form to enroll with Kaiser Permanente.

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.

Electronic Transfer for Payment

Your clients can use this form to authorize their first month payment by electronic transfer.

New Employee Eligibility

Your clients can use this form to document new eligible employees hired in the previous 30 calendar days.

Owner/Officer Eligibility Statement

Your clients can use this form to provide proof of eligibility for proprietors, partners, and corporate officers not appearing on their DE 9C form.

Payroll attestation

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.

Broker — existing group forms

Contact Change Request

Your clients can use this form to change their billing contact, interested party contact, or contract signer information.

Customer Address or Name Change Request

Your clients can use this form to change their company address, name, or federal tax ID (EIN) number.

Employee/Dependent Change

Your clients’ employees can use this form to add or remove dependents from their accounts, change addresses, or change names.

Employee Enrollment

Your clients’ employees can use this form to enroll with Kaiser Permanente.

Employer Attestation for COBRA/ CAL-COBRA & TEFRA Status

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.

Federal COBRA application

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

For more information, please contact the Account Management Support Team at 800-790-4661 option 3.

HIPAA Authorization

Your clients can use this form to authorize use and/or disclosure of patient health information.

Employer Application – 2022

Use this form to enroll with a 2022 effective date.

Employer Application - 2021

Use this form to enroll with a 2021 effective date.

Participation and contribution attestation

Your clients must complete this form to attest that their company continues to meet the minimum participation and contribution requirements for small business coverage.

Payroll attestation

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.

Primary Administrator Online Access Request

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.

Plan Add/Change Request — 2021

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.

Subscriber Termination and Transfer

Your clients can use this form to terminate an employee’s coverage or transfer an employee to a different enrollment unit.

Employer — new group enrollment

Administrative Handbook

Find everything you need to complete your group enrollment and administer your plan in one place.

  • How to get started with Kaiser PermanenteWho to call with your questions
  • Where to get important forms
  • Answers to frequently asked questions
Save time, view your contracts online flyer

Learn how to access and view your current and past contracts 24/7 via your online account. 

Sample DE 9C

This sample DE 9C is the quarterly wage and withholding report for California employers and is used to report wage and payroll tax withholding information for each employee.

Please note each employee’s health coverage status next to their name as shown in this Sample DE 9C.

Employer's confirmation of workers' compensation coverage

Complete this form to confirm you have workers’ compensation coverage for all eligible employees.

Small Business Guidelines

This document provides information about Kaiser Permanente small business coverage, eligibility, rate calculation, benefit plan offering, funding policies, and participation and contribution requirements.

English (PDF)

Employer — new group forms

Employer Application – 2022

Use this form to enroll with a 2022 effective date.

Employer Application - 2021

Use this form to enroll with a 2021 effective date.

Employee Enrollment

Your clients’ employees can use this form to enroll with Kaiser Permanente.

Electronic Transfer for Payment

Use this form to authorize your first month payment by electronic transfer.

Employer — existing group forms

Contact Change Request

Use this form to change billing contact, interested party contact, or contract signer information.

Customer Address or Name Change Request

Use this form to change company address, name, or federal tax ID (EIN) number.

Employee/Dependent Change

Your employees can use this form to add or remove dependents from their accounts, change addresses, or change names.

Employee Enrollment

Your employees can use this form to enroll with Kaiser Permanente.

Electronic Transfer for Payment

Use this form to authorize your first month payment by electronic transfer.

Terminating employee coverage
  • Cal-COBRA packet information - When your employees are no longer covered, Cal-COBRA packets can be sent directly to them by writing “Please send Cal-COBRA packet” at the top of the Subscriber Termination and Transfer, and Reinstatement 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.
Employer Attestation for COBRA/ CAL-COBRA & TEFRA Status

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.

Group Termination

For more information, please contact the Account Management Support Team at 800-790-4661 option 3.

Grievance/Complaint Form

Grievance/Complaint Form is required by CA AB2470 to be provided to the group and for the group to provide it to their employees. Instructions for use and where to submit it are included in the form.

Employer Application Aug - 2021

Use this form to enroll with a 2021 effective date.

Payroll attestation

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.

Plan Add/Change Request — 2021

Use this form to request a midyear change to add or discontinue plans prior to your next renewal.

Subscriber Termination, Transfer and Reinstatement

Use this form to terminate an employee’s coverage or transfer an employee to a different enrollment unit.

Small Business Change of Ownership

Please call our Small Business Account Management Support Team at 800-790-4661, option 3.

Medicare Part D Creditable Coverage Disclosure to CMS Form

Employers who offer prescription drug coverage to Medicare-eligible individuals are required to notify their beneficiaries and the Centers for Medicare & Medicaid Services (CMS) if their coverage is creditable or not.

  1. ALL employers must complete and submit the online Disclosure to CMS form and use the Federal ID #: 94-1340523.
  2. Reference these flyers to determine which plans offer creditable coverage 
    2021 flyer (PDF), or 2020 flyer (PDF).

Find out more information about Part D Creditable Coverage from CMS .

Employer — recertification

Small business recertification

Small business recertification is required annually to confirm that your business still meets the criteria of a small business as defined by the state of California and still qualifies for small business coverage with us.

Recertification booklet

Reference this booklet to review the recertification process, answers to frequently asked questions, a summary of your appeal rights, and a checklist of documents you’re required to submit.

Documents required for recertification

To ensure your recertification is processed quickly and accurately, please submit the following documents along with a copy of your current business license.

  1. Current DE 9C
    The DE 9C form is the quarterly wage and withholding report for California employers and is used to report wage and payroll tax withholding information for each employee.

    Please note each employee’s health coverage status next to their name as shown in this Sample DE 9C (PDF).

  2. Employer's confirmation of workers' compensation coverage (PDF)
    Complete this form to confirm that you have workers’ compensation coverage for all eligible employees in your small business.

  3. Declination and Waiver of Coverage Forms
    • Use the Declination of Coverage form to list all eligible subscribers who have declined Kaiser Permanente coverage. This form doesn't need to be submitted to Kaiser Permanente.

      Declination of Coverage
      English (PDF) | Español (PDF) | 中文 (PDF)Tiếng Việt (PDF)

    • Waiver of Coverage. Your clients' eligible employees can use this form to decline Kaiser Permanente coverage and return to their employer. This form is only for employer records and doesn't need to be submitted to Kaiser Permanente. Employers can use this form to transfer employee information to the Declination of Coverage form.

      Waiver of Coverage
      English(PDF) | Español (PDF) | 中文 (PDF) | Tiếng Việt (PDF)
  4. Owner/officer eligibility statement (PDF)
    Use this form to provide proof of eligibility for proprietors, partners, and corporate officers not appearing on the DE 9C. Additional tax forms may be requested.

  5. Participation and contribution attestation (PDF)
    Complete this form to attest that your company continues to meet the minimum participation and contribution requirements for small business coverage.

If you have additional questions, please call the Recertification Team at 877-490-4983.

Methods to submit your required recertification documents.

Fax: 866-233-7847
Email: recert@kp.org
Mail: Kaiser Permanente
Small Group
Recertification Team
P.O. Box 7094
Pasadena, CA 91109-9641

New employee eligibility documentation
Subscriber termination and transfer
Contact change request
Customer address or name change

Large Business

For your convenience, you can view or download commonly used forms below. If you need additional forms, please contact your account representative at 800-731-4661 (toll free).

Enrollment Forms

HIPAA authorization form
Enrollment application and account change form
Purchaser group application form (for large groups)
Kaiser Permanente Insurance Company employer questionaire

Change Forms

Subscriber termination and transfer sheet
Termination Form

Termination Form is 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.

Other Forms and Support

Schedule A 5500 Report

To request a Schedule A 5500 Report, please contact our California Purchaser Services Unit at 866-752-4737 (toll free).

Individual and Family

Review the 2022 CA KPIF Broker Training Guide (PDF) to get the updates you need for 2022 Open Enrollment, including plan and product updates, an overview of KPIF sales tools and enhancements, compensation details and more.

Enrollment and plan change materials below are in market on November 1, 2020, for January 1, 2021 effective dates.

Effective immediately in California through December 31, 2021, anyone may apply for health coverage due to a special enrollment period without experiencing a qualifying life event or other special circumstance. To enroll your client for coverage or make a plan change, visit Covered California.

Special Enrollment Information and Forms

In general, you can only apply for health care coverage during the yearly open enrollment period. But if you have a qualifying life event, you may be able to apply for coverage for a limited time before or after this event occurs. This is called a special enrollment period.

 

To qualify for a special enrollment period, you must:

  • Have a qualifying life event
  • Have proof of your life event
  • Apply within 60 days of your life event

For some qualifying life events, you can enroll before the date of your event.
Visit kp.org/specialenrollment for more information on qualifying life events and special enrollment periods.

Special Enrollment Period Quick Guide-2021

Refer to this document for limited information about special enrollment periods.

Special Enrollment Period Quick Guide-2020
SEP Proof of Qualifying Life Event Form-2021

Use this form to provide proof of a qualifying life event when enrolling in health care due to a special enrollment period.

SEP Proof of Qualifying Life Event Form-2020

Application for Enrollment

To view some of the most frequently asked about benefits and their copays, coinsurance, and deductibles, please review the Combined Membership Agreement, Evidence of Coverage and Disclosure Forms on the Plan Listing page.

Application for health coverage-2021

Use this form when enrolling in Individual and Family plans.

Application for health coverage-2020

ZIP Code Rate Area Tool

This tool is provided to help you determine your client's rate area. Rate areas are determined by Counties and ZIP codes.

How to use the tool:

  • Open the PDF file
  • Select Edit>Find
  • In the search window, type in ZIP Code
ZIP code rate area tool-2021
ZIP code rate area tool-2020

Enrollment Guides and Rates

Enrollment guide (rate area 1)-2020
Enrollment guide (rate area 2)-2020
Enrollment guide (rate area 3)-2020
Enrollment guide (rate area 4)-2020
Enrollment guide (rate area 5)-2020
Enrollment guide (rate area 6)-2020
Enrollment guide (rate area 7)-2020
Enrollment guide (rate area 8)-2020
Enrollment guide (rate area 9)-2020
Enrollment guide (rate area 10)-2020
Enrollment guide (rate area 11)-2020
Enrollment guide (rate area 12)-2020
Enrollment guide (rate area 13)-2020
Enrollment guide (rate area 14)-2020
Enrollment guide (rate area 15)-2020
Enrollment guide (rate area 16)-2020
Enrollment guide (rate area 17)-2020
Enrollment guide (rate area 18)-2020
Enrollment guide (rate area 19)-2020

Enrollment Guides Without Rates

Open enrollment guide without rates-2020

Dental Value Brochure

Please refer to the dental brochure for information on the optional adult Delta Dental plan underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP), and administered by Delta Dental of California, one of the nation's largest and most experienced dental benefit providers.

Value of Dental Coverage Brochure

Nongrandfathered Plan Change Kit

Please use the following guides and forms to help your clients change plans.

Nongrandfathered Account Change Form-2021

Use this form to make account changes.

Nongrandfathered Account Change Form-2020
Nongrandfathered Health Plan Benefit Highlights-2021

Refer to this document for information about Nongrandfathered health plan benefits.

Nongrandfathered Health Plan Benefit Highlights-2020
Nongrandfathered Rate Chart Guide-2021

Refer to this document for information about Nongrandfathered health plan rates.

Nongrandfathered Rate Chart Guide-2020
SEP Proof of Qualifying Life Event Form-2021

Use this form to provide proof of a qualifying life event when making account changes due to a special enrollment period.

SEP Proof of Qualifying Life Event Form-2020
Special Enrollment Period Quick Guide-2021

Refer to this document for information about special enrollment periods.

Special Enrollment Period Quick Guide-2020

Grandfathered Plan Change Kit

Please use the following guides and forms to help your clients change plans if they are in grandfathered plans.

Grandfathered Acccount Change Form-2021

Use this form to make account changes.

Grandfathered Acccount Change Form-2020
Grandfathered Health Plan Benefit Highlights-2021

Refer to this document for information about Grandfathered health plan benefits.

Grandfathered Health Plan Benefit Highlights-2020
Grandfathered Rate Chart Guide-2021

Refer to this guide for information about Grandfathered health plan rates.

Grandfathered Rate Chart Guide-2020

Broker Support Documents

Broker Attestation Form

You must submit a paper attestation with each paper application.
Submit completed forms to:

  • Email: kpif@kp.org
  • Fax: 1-866-281-1299 (toll free)
    • Attn: Kaiser Permanente for Individual and Family Plans
  • Mail: Kaiser Permanente for Individual and Family Plans
    • 3100 Thornton Ave. Burbank, CA 91504
      • Attn: Broker Sales
Broker Support Services

For a list of KPIF telephone and online solutions, download this reference sheet.

Official logo from Kaiser Permanente Brand Center

Advertise your status as a Kaiser Permanente Authorized Agent.

Client Inquiry Form: Application Status and Billing

If you have multiple questions about Kaiser Permanente for Individuals and Families (KPIF) applications, billing and administration, you will find it more efficient to fill out a client inquiry form and send it to KPIF@kp.org. This streamlined process will help ensure your questions are resolved quickly.

Client Inquiry Form: Compensation
HIPAA Authorization Form

Download and save our HIPAA form.

Other Forms and Support

If you have questions, please email the Broker Services Team at KPIF@kp.org or call 1-844-394-3978.