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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'ABOUT BUSINESS' section. Enter your legal business name, DBA, physical address, and contact information. Ensure all details are accurate as they will be used for correspondence.
- In the 'OTHER MEDICAL COVERAGE' section, indicate whether your company has existing group coverage and provide necessary details if applicable.
- Complete the 'EMPLOYER ELIGIBILITY' and 'EMPLOYEE COUNT' sections by providing information about your employee numbers and any affiliations with other companies.
- Fill out the 'DOMESTIC PARTNER COVERAGE' and 'CONTINUATION COVERAGE' sections based on your company's policies regarding domestic partners and COBRA eligibility.
- Provide details in the 'EMPLOYER PREMIUM CONTRIBUTION' section regarding how much of the premium you will cover for employees.
- Finally, review all sections for accuracy before signing in the 'AGREEMENT AND SIGNATURE' section to confirm your understanding and agreement with Kaiser Permanente's terms.
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