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Enrollment Kit - Kaiser Permanente (Medical)

This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.
Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval.  The following list outlines Kaiser Permanente’s case submission requirements.​​
  • New Group Application:
    • The application must be completed, including the signature of the authorized company officer and date of signature.
    • If the application is submitted without your signature, it will be returned, delaying implementation of your group’s coverage.
    • Make sure that all broker information is completed, if applicable.
    • Make sure your contract delivery method is indicated.
    • New Group Application - Effective 1/1/2019
    • New Group Application - Effective 1/1/2020
  • Employee Enrollment Application​​​
  • It is very important that you communicate the type of plan and plan name to your employees.  They will need to check the plan name in the following places:
    • On the cover of their Enrollment Booklets, in order to reference information about their benefits, and
    • On their Temporary Membership ID Form (located in the Employee Enrollment Booklet).
  • Make sure all enrolling employees complete, sign and date an Enrollment Form located in the Employee Enrollment Booklet.    The form must include the following:
    • Company name
    • New group account box checked
    • Social Security numbers and dates of birth for all family members to be included in the coverage
    • Employee’s signature on the application
  • Declination of coverage:
    • All eligible employees who are refusing coverage must complete the Declination of Coverage​​​.  A minimum of 70 percent of all eligible employees must have group health plan coverage.
  • Initial premium payment:
    • At the time of enrollment, a copy of a business check in the amount of the first month’s premium and payable to Kaiser Permanente must be submitted with your application.  For your convenience, the Electronic Check Authorization Form (2019) / Electronic Check Authorization Form (2020)may be submitted instead of a check.
      • ​Once your group has been approved, a mailing address for submitting the original check will be provided or the premium will be withdrawn directly from your account, depending on which option you have chosen.
  • Company contribution to employee premium:
    • The contribution can be a percent or a fixed dollar amount.  Minimum contribution is at least 50 percent of the premium of the lowest plan offered by the company.
  • Proprietor / Partnership / Corporate Officer Form​:
    • ​Must be completed for each Proprietor/Partner/Corporate Officer enrolling not listed on the DE-9C​ or payroll report.
  • Owner-only groups:
    • Owner-only groups enrolling, such as a husband and wife with or without children, must qualify as a business by providing Proprietor / Partnership /​ Corpor​ate Officer Form​​ and one additional document, including but not limited to the following:
      • ​Business license
      • DBA (Doing Business As)​, a copy of the Fictitious Business Name Statement must be provided to link the legal name to the DBA.
      • ​Contractor’s license
      • ​Seller’s permit
  • Sole Proprietorship:
    • If a co-owner is a spouse and is not listed, the following must be submitted, along with the Proprietor / Partnership / Corp​orate Officer Form​:
      • 1040 Schedule C​ for the preceding calendar year.
      • ​One of the eligibility documents listed under the “Owner-only Groups” section.
  • Corporations:
    • For corporations, submit the Proprietor / Partnership / Corporate Officer Formand one additional document, including but not limited to the following:
      • Articles of Incorporation including officers and Schedule K-1​.
      • Statement of Information by Domestic Stock Corporation.
      • ​Shareholder/Stock Certificates.
      • ​Tax Form: 1120​ or 2553​.
  • DE-9C ​Quarterly Wage Report or Payroll Report - Please include:
    • DE-9C from the previous quarter (note updated employee status, i.e., part-time, full-time or terminated, and name of the other carrier if the employee has other coverage or through the spouse’s employer).
    • Payroll records from within the last 30 days for employees hired after the DE-9C filing.
    • Proof of owner’s/employer’s eligibility, if the owner/employer is not listed on the DE-9C (see Proprietor / Partnership / Corporate Officer Form​​ section).

​​​After approval, prior carrier termination letter must be submitted by the employer or broker.

For other useful or older documents, please refer to the Forms database.
Important Reminder:  To help your client comply with ACA requirements, provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at the Enrollment Meeting, via email or by posting on an internal company website.  For the most recent information regarding Kaiser Permanente’s SBCs, please go to the SBC Page or contact your Word & Brown Representative.