Employee/dependent Change Form
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EMPLOYEE/DEPENDENT CHANGE
INSTRUCTIONS
1. The employer must complete Section A.
2. The employer is responsible for confirming all information prior to submitting. Please make sure effective dates are correct as these affect health
plan premiums.
3. The employee must complete Sections B through E.
4. The employee must sign and date the bottom of the form.
5. Once all sections are complete, the employee should make a copy for his or her records and give the completed form to the employer.
6. The employer should give the completed form to his or her Kaiser Permanente representative or broker.
7. This form is not an employee termination of coverage request. If you would like to terminate an employee’s coverage, please use the
Subscriber Termination/Transfer form.
All changes to accounts, including effective dates and dependent status, will be made in accordance with the contractual agreement between the
employer/purchaser and Kaiser Permanente. If your address changes, then your rate may change.
A COMPANY INFORMATION
Company name
Customer ID
Enrollment unit
Street address
City
State
ZIP
County
Office phone
Ext.
Fax
Email
(
)
–
(
)
–
B REQUESTED CHANGES
Add dependents (complete sections C, D, and E )
Reason (see section F ):
Event date:
Delete dependents (complete sections C, D, and E )
Reason (see section F ):
Event date:
Employee name change (complete sections C, D, and E )
From:
To:
Event date:
Employee address (complete section C )
Employee phone (complete section C )
C EMPLOYEE INFORMATION
Name (first, MI, last)
Medical record number
Home address
First day of residency at this
City
State
ZIP
County
address
/
/
Home phone
Office phone
Ext.
Email
(
)
–
(
)
–
Small Business
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60215010_V2 July 2014
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Parent category: Business