• 2-in-1 employee benefit designation form
• 3-in-1 employee benefit designation form
• Renewal response form
• Enrollment/change of information form

The renewal decision form is the tool used to change benefits at renewal, or to simply renew with no additional changes. The rates and benefits chosen will begin on the date of the renewal. Return of this form is required for all renewals.

Consider the options carefully as changes can only be made at the time of renewal.

Replying to us with the renewal changes 7 weeks prior to the effective date will allow us time to process changes and provide an accurate bill for the renewal month. Benefit changes can be requested up to the 15th of the month prior to the date of renewal; however, the bill may not reflect the change/adjustment until the [following] month after the renewal.

1. Review the renewal packet for benefit changes, renewal rates and plan options.
2. Select the benefits that best meet your client's needs. See our plans and products brochure.
3. Complete the renewal decision form.
4. Submit the Kaiser Permanente employee enrollment/change form for employees and/or dependents newly enrolling in the group plan.
5. Submit the completed and signed benefit designation form for groups electing a bundled plan (all enrolling employees must sign 2-in-1 form or 3-in-1 form). If bundled benefits are being renewed, only employees wishing to switch plans need to complete and sign the form. For new employees, they will need to complete the enrollment/change of information form as well as the employee benefit designation form.
6. Fax, mail, or email the completed forms to your Kaiser Permanente representative. We must receive this information no later than the fifteenth of the month prior to the date of renewal.

Fax: 1-877-237-5546

Mail: Kaiser Permanente
Small Business Group
500 NE Multnomah St., Suite 100
Portland, OR 97232

Email: small.group.respond@kp.org

Please contact a representative if you have questions regarding the renewal process.

• Employee census form for small group
• Employer application: Oregon small business
• Employer application: Washington small business