Fillable Employee Enrollment Form (Page 2 of 3) in pdf

Small Business

EMPLOYEE ENROLLMENT

See instructions on page 1 before completing this form. Make a copy for your records.

1 TO BE COMPLETED BY EMPLOYER

New group account

Existing account

Company name

Customer ID (if assigned)

Date of coverage to be effective (mm/dd/yyyy)

Plan selection

Employee classification (if applicable)

Employee last name

Employee first name

Enrollment reason (Please check 1)

New group account

New hire

Open enrollment

Part-time to full-time

Loss of coverage

Other:

If you have an existing account, please fax this form to 858-614-3345 (SCAL), 858-614-3344 (NCAL), or email .

2 TO BE COMPLETED BY EMPLOYEE

Have you ever been a member of, or received care from, Kaiser Permanente in California?

Yes

If so, under what medical record number (if known)

Social Security number

Former/Maiden name

Last name

First name

Preferred language (optional)

Home address (no P.O. boxes)

City

State

ZIP

County

Date of birth

Gender

Day phone

Evening phone

If you decline coverage for yourself or an eligible dependent, you can only enroll or change your coverage during an annual open enrollment period established

by your employer, or during a special enrollment period if you have experienced a triggering event. You must request coverage within 60 days of a triggering

event. Special enrollment triggering events include:

Loss of health care (minimal essential) coverage, resulting from any of the following: loss of employer-sponsored coverage because you and/or your

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dependent no longer meet the eligibility requirements, or your employer no longer offers coverage or stops contributing premium payments; loss of

eligibility for COBRA coverage (for a reason other than termination for cause or nonpayment of premium); your and/or your dependent’s individual,

Medi-Cal, Medicare, or other governmental coverage ends; or for any reason other than failure to pay premiums on a timely basis or situations allowing

for a rescission (fraud or intentional misrepresentation of material fact); or loss of health care coverage including, but not limited to, loss of that coverage

due to the circumstances described in Section 54.9801-6(a)(3)(i) to (iii), inclusive, of Title 26 of the Code of Federal Regulations and the circumstances

described in Section 1163 of Title 29 of the United States Code;

Gaining or becoming a dependent due to marriage, domestic partnership, birth, adoption, placement for adoption, or assumption of a parent-child

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relationship;

A valid state or federal court orders that you or your dependent be covered;

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Permanent relocation, such as moving to a new location and having a different choice of health plans, or being released from incarceration;

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The prior health coverage issuer substantially violated a material provision of the health coverage contract;

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A network provider’s participation in your and/or your dependent’s health plan ended when you and/or your dependent(s) were under active care for one of

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the following conditions: an acute condition (an acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury,

or other medical problem that requires prompt medical attention and that has a limited duration); a serious chronic condition (a serious chronic condition

is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure

or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration); pregnancy; terminal illness

(a terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less); care of a newborn child

between birth and age 36 months; or performance of a surgery or other procedure that has been recommended and documented by the provider to occur

within 180 days of the contract’s termination date or within 180 days of the effective date of coverage for a newly covered insured;

A member of the reserve forces of the United States military returning from active duty or a member of the California National Guard returning from active

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duty service under Title 32 of the United States Code;

An individual demonstrates to the Department of Managed Health Care or Department of Insurance, as applicable, with respect to health benefit plans

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offered outside the Exchange that the individual did not enroll in a health benefit plan during the immediately preceding enrollment period available because

the individual was misinformed that he or she was covered under minimum essential coverage.

Small Business

60514111 January 2017

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