Individuals and Families

Individuals and families (KPIF)

Accessing the right forms for your clients is easy. Below are commonly used forms for the KPIF line of business. 

KPIF Applications and Account Change Forms

These forms can be used to apply for individual or family coveraged provided by Kaiser Foundation Health Plan of the Northwest. Individuals can also apply online at buykp.org/apply

Oregon KPIF Application

2022 English (PDF) – Coming Soon | 2022 Spanish (PDF) – Coming Soon
2021 English (PDF) | 2021 Spanish (PDF)

Washington (Clark & Cowlitz Counties) KPIF Application

2022 English (PDF) – Coming Soon | 2022 Spanish (PDF) – Coming Soon
2021 English (PDF) | 2021 Spanish (PDF)

Oregon KPIF Account Change Form

Oregon KPIF Account Change Form
2022 English (PDF) – Coming Soon | 2022 Spanish (PDF) – Coming Soon
2021 English (PDF) | 2021 Spanish (PDF)

2022 NW-WA KPIF Account Change Form

Members may use this form to make account or plan changes in Clark or Cowlitz Counties.
2022 English (PDF) – Coming Soon | 2022 Spanish (PDF) – Coming Soon
2021 English (PDF) | 2021 Spanish (PDF)

Special Enrollment

Outside of the open enrollment period, individuals can enroll or change coverage if they have experienced a situation known as a tiggering event. Examples of triggering events include getting married, having a baby, or losing coverage due to the loss of a job. For more information regarding special enrollment periods, please visit kp.org/specialenrollment.

Special Enrollment Qualifying Life Event Form

2022 English (PDF) – Coming Soon | 2022 Spanish (PDF) – Coming Soon 

2021 Special Enrollment Qualifying Life Event Form

Other Forms and Support

Agent of Record Form

Authorization for insurance agent/producer to act on behalf of an applicant.

Oregon Non-Tobacco Declaration Form

Oregon Form for Reduced Non-Tobacco Premium

Washington Non-Tobacco Declaration Form

Clark and Cowlitz Counties form for Reduced Non-Tobacco Premium

KPIF Broker Support Services Flier

Flier outlining contact information for inquiries on enrollment status & membership, compensation, and new sales.

Summary of Benefits and Coverage (SBC) for KPIF Plans

To download an SBC, please visit kp.org/sbc and select your region and plan.

Glossary of Health Coverage and Medical Terms
Health Care Reform SBC Q&As

Small Business

Accessing the right forms for your clients is easy. Below are commonly used forms for the small businesses line of business. 

Employer Forms

2021 Small Group employer application (OR)
2021 Small Group employer application (WA)
2021 Group profile form for renewing groups (OR)
2021 Group profile form for renewing groups (WA)
2021 Dental employer application (OR)
2021 Dental employer application (WA)
2021 Census form (OR)
2021 Census form (WA)
Employer Attestation Declination of Coverage (OR)
Employer Attestation Declination of Coverage (WA)
Bill Delivery Preference Form for Groups in Washington

Employee Forms

2021 Small Group employee enroll/change form—fillable (OR)
2021 Small Group employee enroll/change form—fillable (WA)
2021 Additional Dependent Form – Small Group (OR)
2021 Additional Dependent Form – Small Group (WA)
2021 Employee Declination of Coverage (OR)
2021 Employee Declination of Coverage (WA)
2021 Waiver of group insurance for Small Business Groups (OR)
2021 Waiver of group insurance for Small Business Groups (WA)

Large Business

Accessing the right forms for your clients is easy. Below are commonly used forms for the large businesses line of business. 

Employer Forms

2021 New and Renewing Large Group Application
Enrollment Application Certification Checklist for Washington State - Paper
Enrollment Application Certification Checklist for Washington State - Online

Employee Forms

2021 Large Group employee enroll/change form—fillable (OR)
2021 Large Group employee enroll/change form—fillable (WA)
2021 Additional Dependent Form — OR Large Group
2021 Additional Dependent Form — WA Large Group