Fillable Enrollment Form printable pdf download

COBRA Enrollment Form

This enrollment form must not be submitted to Kaiser Permanente. Ask your former employer where you should send this form.

Complete all fields or you may have a delay in your enrollment. Please print or type in black or dark blue ink only.

TO BE COMPLETED BY EMPLOYER

Purchaser/Enrollment Unit

Employer

Employer Signature/Date

Number

Reason for COBRA Enrollment

Enrollment Information



Date of termination of employment: MO ______ DAY ______ YEAR ______

Date of reduction of work hours: MO ______ DAY ______ YEAR ______



Loss of spousal or dependent status: Effective Date of Loss: MO ______ DAY ______ YEAR ______



Please check the reason for

Reason for loss:  Marriage  Divorce or legal separation  Death of subscriber  Reached maximum age ____

enrollment and complete the

 Subscriber’s Medicare entitlement  Other ______

maximum months of coverage.

Transfer of existing COBRA account from another carrier to Kaiser Permanente



NOTE: If requesting a transfer

Carrier’s Name & Telephone Number _______________________________________________________________

of an existing COBRA account

Policy Number _________________________ Policy Term Date _________________________

from another carrier to Kaiser

Original initial COBRA enrollment reason ______________________________

Permanente, you must indicate

Original initial COBRA coverage start date _______________

the qualifying event for the

Maximum months of coverage

_____________

initial COBRA enrollment.

Additional Enrollment Information

Qualified beneficiary on the account is disabled pursuant to US Social Security Act



Applying for Health Care Tax Credit (TAA/HCTC) through the Federal Government.



(Please attach a copy of your potential eligibility letter.)

TO BE COMPLETED BY EMPLOYEE

Please list all members to be enrolled in the account. With the exception of annual Open Enrollments or Special Enrollments due to HIPAA, only a spouse and

dependent children included in the prior group coverage may be enrolled as part of your COBRA account. (Attach additional sheet, if needed.)

Subscriber Information

Name: (Last/First/MI)

Social Security number

Date of birth

Gender

Address: (Street/City/State/ZIP)

Day phone number

Alternate phone number

Email address (for enrollment purpose only)

During this employment was Kaiser Permanente your group coverage?

 Yes

 No

Family Information

Spouse or

Name: (Last/First/MI)

Role

Social Security number

Date of birth

Gender

domestic

 Spouse

partner (if

 Domestic partner

eligible)

Dependent

 Child

 Student

Dependent

 Child

 Student

I, on behalf of myself and my family members listed on this Form, if any, agree to be bound by the benefits, co-payments, deductibles, exclusions, limitations and other terms

and conditions of the Group health plan documents, including the Evidence of Coverage. I have reviewed the statements on this form and they are true and correct. The Health

Plan reserves the right to rescind or terminate coverage if any material misrepresentation is made in this Form.

Kaiser Foundation Health Plan, Inc. and Kaiser Permanente Insurance Company Arbitration Agreement*: I understand that (except for Small Claims

Court cases, claims subject to a Medicare appeals procedure, and, if I am enrolled in coverage that is subject to the ERISA claims procedure

regulation (29 CFR 2560.503-1), certain benefit-related disputes*) any dispute between myself, my heirs, relatives, or other associated parties on the

one hand and Kaiser Foundation Health Plan, Inc. (KFHP), Kaiser Permanente Insurance Company (KPIC), 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 or

coverage by KPIC, 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 and in the Certificate of Insurance.

* Disputes arising from any of the following KPIC products are not subject to binding arbitration: 1) Tiers 2 & 3 of the Point of Service (POS)

Plans; 2), the Preferred Provider Organization (PPO) and Out of Area Indemnity (OOA) Plans; and 3), the KPIC Dental plans.

Signature Required for all Kaiser Permanente Plans

Date

(Excluding KPIC PPO, KPIC OOA, and KPIC Dental Plans)

Enrollment Form

Related Articles

Related forms

Related Categories