Employee Enrollment Form Page 3
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3Small Business
EMPLOYEE ENROLLMENT
3 FAMILY INFORMATION
(Please list only those family members to be enrolled.)
Date of birth (mm/dd/yyyy)
Gender
Social Security number
Spouse
Domestic partner
M
F
Name (Last, First, MI)
Medical record number (if known)
Date of birth (mm/dd/yyyy)
Gender
Social Security number
Dependent
M
F
Name (Last, First, MI)
Medical record number (if known)
Date of birth (mm/dd/yyyy)
Gender
Social Security number
Dependent
M
F
Name (Last, First, MI)
Medical record number (if known)
Date of birth (mm/dd/yyyy)
Gender
Social Security number
Dependent
M
F
Name (Last, First, MI)
Medical record number (if known)
Date of birth (mm/dd/yyyy)
Gender
Social Security number
Dependent
M
F
Name (Last, First, MI)
Medical record number (if known)
Date of birth (mm/dd/yyyy)
Gender
Social Security number
Dependent
M
F
Name (Last, First, MI)
Medical record number (if known)
Do any of your dependents listed above live at another address?
Yes
No
If Yes, complete the following:
Name (Last, First, MI)
Address
4 SIGNATURE
KAISER FOUNDATION HEALTH PLAN, INC., ARBITRATION AGREEMENT*
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure regulation,
and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other
associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers, administrators, or other
associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP, including any claim for
medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently
rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided
by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of
arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration
provision is contained in the Evidence of Coverage.
Employee name (please print)
Title (please print)
Employee signature
Date
X
* Disputes arising from fully insured Kaiser Permanente Insurance Company (KPIC) coverage are not subject to binding arbitration: 1) Preferred
Provider Organization (PPO) plans and 2) KPIC Dental plans.
Small Business
60514111 January 2017
Page 3 of 3
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