Use our electronic signature forms for fast and convenient routing directly to KP for processing. Simple PDF forms are no longer available for download where electronic signature links are available.
Resources to support your clients for a smooth enrollment process.
Help avoid processing delays — use the most current forms to complete every section and sign before you submit. Forms not listed on this matrix are outdated and won't be accepted for processing.
Use this form for new and renewing groups.
Use this form to enroll with a January – December 2024 effective date.
Use this form to enroll with a January – December 2023 effective date.
Your clients’ employees can use this form to enroll with Kaiser Permanente. Avoid service delays — The signature must be under the Arbitration Agreement and not above it. If it’s not signed correctly, Small Business Accounts will not enroll the member and will need to request a new signature on the form.
Your clients can use this form to authorize their first month payment by electronic transfer.
Use this checklist to:
Find everything you need to complete your group enrollment and administer your plan in one place.
Get information about Kaiser Permanente's approach to evaluating and offering coverage to new and existing small business accounts.
This document provides information about Kaiser Permanente small business coverage, eligibility, rate calculation, benefit plan offering, funding policies, and participation and contribution requirements.
Use this form if a group will offer Kaiser Permanente HMO (and PPO) in California while offering an alternative funded plan or composite rate plan out-of-state.
Declination of Coverage
Submit a Declination of Coverage form to list all eligible subscribers who have declined Kaiser Permanente coverage.
English (PDF) | Español (PDF) | 中文 (PDF) | Tiếng Việt (PDF)
Waiver of Coverage
Your clients' eligible employees can use this form to decline Kaiser Permanente coverage and return to their employer. This form is only for employer records and doesn't need to be submitted to Kaiser Permanente. Employers can use this form to transfer employee information to the Declination of Coverage form.
Your clients can use this form to provide proof of eligibility for proprietors, partners, and corporate officers not appearing on their DE 9C form.
Your clients must complete this form to attest that their company continues to meet the minimum participation and contribution requirements for small business coverage.
Your clients can use this form if they're a new business (start-up, breakaway or establishing payroll from an existing business) and don't have payroll to document eligible employees.
This sample DE 9C is the quarterly wage and withholding report for California employers and is used to report wage and payroll tax withholding information for each employee. Please note each employee’s health coverage status next to their name as shown in this Sample DE 9C.
Learn how to access and view your current and past contracts 24/7 via your online account.
Complete this form to confirm you have workers’ compensation coverage for all eligible employees.
Use our electronic signature forms for fast and convenient routing directly to KP for processing. Simple PDF forms are no longer available for download where electronic signature links are available.
Use our new electronic signature form – completed documents will route directly to KP for processing.
Save time and submit your Contact Change Request online by logging into your account at account.kp.org. Changes to your group contacts are immediate.
Use our electronic signature form to send the request directly to Kaiser Permanente and your group contact changes will be processed within 2-4 days.
Your clients can use this form to change their company address, name, or federal tax ID (EIN) number.
Use our new electronic signature form – completed documents will route directly to KP for processing.
Your clients’ employees can use this form to add or remove dependents from their accounts, change addresses, or change names.
Use our new electronic signature form – completed documents will route directly to KP for processing.
Your clients’ employees can use this form to enroll with Kaiser Permanente. Avoid service delays — The signature must be under the Arbitration Agreement and not above it. If it’s not signed correctly, Small Business Accounts will not enroll the member and will need to request a new signature on the form.
Use our new electronic signature form – completed documents will route directly to KP for processing.
Use this form to let us know if you have a COBRA status change from Cal-COBRA to Federal COBRA or Federal COBRA to Cal-COBRA. Write in the effective date of change on the form.
Use our new electronic signature form – completed documents will route directly to KP for processing.
For groups with 20+ eligible employees, use the Federal COBRA application to cover your client’s former employees and their dependents. For groups with 2–19 eligible employees, your client’s former employees must contact the Kaiser Permanente Member Service Contact Center at 1-800-464-4000 for enrollment assistance.
Grievance/Complaint Form is required by CA AB2470 to be provided to the group and for the group to provide it to their employees. Instructions for use and where to submit it are included in the form.
For more information, please contact the Account Management Support Team at 1-800-790-4661 option 3.
Your clients can use this form to authorize use and/or disclosure of patient health information.
Your clients can use this form to document new eligible employees hired in the previous 30 calendar days.
Groups that have already renewed for 2024 and wish to add or discontinue plans should use this form to request a midyear plan change prior to their next renewal.
Use our new electronic signature form – completed documents will route directly to KP for processing.
Groups that have already renewed for 2023 and wish to add or discontinue plans should use this form to request a midyear plan change prior to their next renewal.
Use our new electronic signature form – completed documents will route directly to KP for processing.
Use our new electronic signature form – completed documents will route directly to KP for processing.
Use this form when terminating employee coverage. Please note below for terminating Cal-COBRA employees.
Cal-COBRA packet information - When your employees are no longer covered, Cal-COBRA packets can be sent directly to them by writing “Please send Cal-COBRA packet” at the top of the Subscriber Termination and Transfer, and Reinstatement form. Be sure to confirm the correct member mailing address is on file with us prior to submitting the form.
Use our new electronic signature form – completed documents will route directly to KP for processing.
Small business recertification is required annually to confirm that your business still meets the criteria of a small business as defined by the state of California and still qualifies for small business coverage with us.
Reference this booklet to review the recertification process, answers to frequently asked questions, a summary of your appeal rights, and a checklist of documents you’re required to submit.
To ensure your recertification is processed quickly and accurately, please submit the following documents along with a copy of your current business license.
1. Current DE 9C: The DE 9C form is the quarterly wage and withholding report for California employers and is used to report wage and payroll tax withholding information for each employee.
Please note each employee’s health coverage status next to their name as shown in this Sample DE 9C (PDF).
2. Employer's confirmation of workers' compensation coverage (PDF)
Complete this form to confirm that you have workers’ compensation coverage for all eligible employees in your small business.
3. Declination and Waiver of Coverage Forms
Use the Declination of Coverage form to list all eligible subscribers who have declined Kaiser Permanente coverage. This form doesn't need to be submitted to Kaiser Permanente.
Declination of Coverage
English (PDF) | Español (PDF) | 中文 (PDF) | Tiếng Việt (PDF)
Waiver of Coverage. Your clients' eligible employees can use this form to decline Kaiser Permanente coverage and return to their employer. This form is only for employer records and doesn't need to be submitted to Kaiser Permanente. Employers can use this form to transfer employee information to the Declination of Coverage form.
Waiver of Coverage
English(PDF) | Español (PDF) | 中文 (PDF) | Tiếng Việt (PDF)
4. Owner/officer eligibility statement (PDF)
Use this form to provide proof of eligibility for proprietors, partners, and corporate officers not appearing on the DE 9C. Additional tax forms may be requested.
5. Participation and contribution attestation (PDF)
Complete this form to attest that your company continues to meet the minimum participation and contribution requirements for small business coverage.
If you have additional questions, please call the Recertification Team at 877-490-4983.
Methods to submit your required recertification documents.
Fax: 866-233-7847
Email: recert@kp.org
Mail: Kaiser Permanente Small Group
Recertification Team
P.O. Box 7094
Pasadena, CA 91109-9641
For your convenience, you can view or download commonly used forms below. If you need additional forms, please contact your account representative at 800-731-4661 (toll free).
Termination Form is required by CA AB2470 to be provided to the group and for the group to provide to their employees. Instructions for use and where to submit included in the form.
To request a Schedule A 5500 Report, please contact our California Purchaser Services Unit at 866-752-4737 (toll free).
Review the 2024 CA KPIF Broker Training Guide (PDF) to get the updates you need for 2024 Open Enrollment, including plan and product updates, an overview of KPIF sales tools and enhancements, compensation details and more.
Enrollment and plan change materials below are in market on November 1, 2023, for January 1, 2024 effective dates.
In general, you can only apply for health care coverage during the yearly open enrollment period. But if you have a qualifying life event, you may be able to apply for coverage for a limited time before or after this event occurs. This is called a special enrollment period.
To qualify for a special enrollment period, you must:
For some qualifying life events, you can enroll before the date of your event.
Visit kp.org/specialenrollment for more information on qualifying life events and special enrollment periods.
Refer to this document for limited information about special enrollment periods.
Refer to this document for limited information about special enrollment periods.
Use this form to provide proof of a qualifying life event when enrolling in health care due to a special enrollment period.
Use this form to provide proof of a qualifying life event when enrolling in health care due to a special enrollment period.
To view some of the most frequently asked about benefits and their copays, coinsurance, and deductibles, please review the Combined Membership Agreement, Evidence of Coverage and Disclosure Forms on the Plan Listing page.
Use this form when enrolling in Individual and Family plans.
Use this form when enrolling in Individual and Family plans.
Please refer to the dental brochure for information on the optional adult Delta Dental plan underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP), and administered by Delta Dental of California, one of the nation's largest and most experienced dental benefit providers.
Please use the following guides and forms to help your clients change plans.
Use this form to make account changes.
Use this form to make account changes.
Refer to this document for information about Nongrandfathered health plan benefits.
Refer to this document for information about Nongrandfathered health plan benefits.
Refer to this document for information about Nongrandfathered health plan rates.
Refer to this document for information about Nongrandfathered health plan rates.
Use this form to provide proof of a qualifying life event when making account changes due to a special enrollment period.
Use this form to provide proof of a qualifying life event when making account changes due to a special enrollment period.
Refer to this document for information about special enrollment periods.
Refer to this document for information about special enrollment periods.
Please use the following guides and forms to help your clients change plans if they are in grandfathered plans.
Use this form to make account changes.
Use this form to make account changes.
Refer to this document for information about Grandfathered health plan benefits.
Refer to this guide for information about Grandfathered health plan rates.
You must submit a paper attestation with each paper application.
Submit completed forms to:
For a list of KPIF telephone and online solutions, download this reference sheet.
Advertise your status as a Kaiser Permanente Authorized Agent.
If you have multiple questions about Kaiser Permanente for Individuals and Families (KPIF) applications, billing and administration, you will find it more efficient to fill out a client inquiry form and send it to KPIF@kp.org. This streamlined process will help ensure your questions are resolved quickly.
Download and save our HIPAA form.
If you have questions, please email the Broker Services Team at KPIF@kp.org or call 1-844-394-3978.