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.
Small Business
Small business enrollment
Resources to support your clients for a smooth enrollment process.
Form Validation Matrix
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 Forms not listed on this matrix are outdated and won't be accepted for processing.
New Group Enrollment
Broker Census
Use this form for new and renewing groups.
Employer Application - 2025
Use this form to enroll with a January – December 2025 effective date.
English (PDF)
Employer Application – 2024
Use this form to enroll with a January – December 2024 effective date.
Employee Enrollment
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.
Electronic Transfer of Payment
Your clients can use this form to authorize their first month payment by electronic transfer.
New Group Enrollment Checklist
Use this checklist to:
- Ensure key documents are completed for a quick submission
- Learn additional enrollment tips
Employee Assistance Program (EAP) from TELUS Health:
Supporting Materials for Setting Up New Groups
Administrative Handbook
Find everything you need to complete your group enrollment and administer your plan in one place.
- How to get started with Kaiser Permanente
- Who to call with your questions
- Where to get important forms
- Answers to frequently asked questions
Underwriting Guidelines
Get information about Kaiser Permanente's approach to evaluating and offering coverage to new and existing small business accounts.
Employer - Small Business Guidelines
This document provides information about Kaiser Permanente small business coverage, eligibility, rate calculation, benefit plan offering, funding policies, and participation and contribution requirements.
Attestation for Alternative Funded Plans/Composite Rates
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 and Waiver of Coverage Forms
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.
Owner/Office Eligibility Statement
Your clients can use this form to provide proof of eligibility for proprietors, partners, and corporate officers not appearing on their DE 9C form.
Participation and Contribution Attestation
Your clients must complete this form to attest that their company continues to meet the minimum participation and contribution requirements for small business coverage.
Sample DE 9C
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.
Save time, view your contracts online flyer
Learn how to access and view your current and past contracts 24/7 via your online account.
Employers Confirmation of Workers Compensation Coverage
Complete this form to confirm you have workers’ compensation coverage for all eligible employees.
Existing Group Support
Broker of Record Authorization (Existing Group)
Use our new electronic signature form – completed documents will route directly to KP for processing.
Consolidated Appropriations Act and Transparency in Coverage LOA
Contact Change Request
Save time and submit your Contact Change Request online by logging into your account at business.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.
Customer Name or Address Change Request
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.
Employee/Dependent Change
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.
Employee Enrollment
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.
Federal COBRA & Cal-COBRA Status Change
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. Input the effective date of change on the form.
Use our new electronic signature form – completed documents will route directly to KP for processing.
Federal COBRA application
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
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.
Group Termination
For more information, please contact the Account Management Support Team at 1-800-790-4661 option 3.
HIPAA Authorization
Your clients can use this form to authorize use and/or disclosure of patient health information.
New Employee Eligibility
Your clients can use this form to document new eligible employees hired in the previous 30 calendar days.
Plan Add/Change Request - 2025
Groups that have already renewed for 2025 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.
Plan Add/Change Request - 2024
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.
Primary Administrator Online Access Request
Use our new Online Account Services Request Form – completed documents will route directly to KP for processing.
Subscriber Termination, Transfer, and Reinstatement
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 selecting “Check box to request Cal-COBRA information” in Section 2 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 Change of Ownership
Employer Recertification
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.
Recertification booklet
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.
Documents required for recertification
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
New employee eligibility documentation
Employee/dependent change request
Employee enrollment form
Subscriber termination and transfer
Contact change request
Customer name or address change
Large Business
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).
Enrollment Forms
HIPAA authorization form
Enrollment application and account change form
Purchaser group application form (for large groups)
Kaiser Permanente Insurance Company employer questionnaire
Change Forms
Subscriber termination and transfer sheet
Termination Form
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.
Other Forms and Support
Consolidated Appropriations Act and Transparency in Coverage LOA
Schedule A 5500 Report
To request a Schedule A 5500 Report, please contact our California Purchaser Services Unit at 866-752-4737 (toll free).
Employee Assistance Program (EAP) from TELUS Health:
Individual and Family
Review the 2025 CA KPIF Broker Training Guide (PDF) to get the updates you need for 2025 Open Enrollment, including plan and product updates, an overview of KPIF sales tools and enhancements, compensation details and more.
Review the KPIF Broker Frequently Asked Questions below for answers to common questions about selling Kaiser Permanente for Individual and Family Plans (KPIF) and working with KP.
Enrollment and plan change materials below are in market on November 1, 2024, for January 1, 2025 effective dates.
Special Enrollment Information and Forms
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:
- Have a qualifying life event
- Have proof of your life event
- Apply within 60 days of your life event
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.
Special Enrollment Period Quick Guide-2025
Refer to this document for limited information about special enrollment periods.
Special Enrollment Period Quick Guide-2024
Refer to this document for limited information about special enrollment periods.
SEP Proof of Qualifying Life Event Form-2025
Use this form to provide proof of a qualifying life event when enrolling in health care due to a special enrollment period.
SEP Proof of Qualifying Life Event Form-2024
Use this form to provide proof of a qualifying life event when enrolling in health care due to a special enrollment period.
Application for Enrollment
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.
Application for health coverage-2025
Use this form when enrolling in Individual and Family plans.
Application for health coverage-2024
Use this form when enrolling in Individual and Family plans.
Enrollment Guides and Rates
Enrollment guide-2025
Enrollment guide-2024
Nongrandfathered Rate Chart Guide-2025
Nongrandfathered Rate Chart Guide-2024
Dental Value Brochure
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.
Value of Dental Coverage Brochure
Nongrandfathered Plan Change Kit
Please use the following guides and forms to help your clients change plans.
Nongrandfathered Account Change Form-2025
Use this form to make account changes.
Nongrandfathered Account Change Form-2024
Use this form to make account changes.
Nongrandfathered Health Plan Benefit Highlights-2025
Refer to this document for information about Nongrandfathered health plan benefits.
Nongrandfathered Health Plan Benefit Highlights-2024
Refer to this document for information about Nongrandfathered health plan benefits.
Nongrandfathered Rate Chart Guide-2025
Nongrandfathered Rate Chart Guide-2024
Refer to this document for information about Nongrandfathered health plan rates.
SEP Proof of Qualifying Life Event Form-2025
Use this form to provide proof of a qualifying life event when making account changes due to a special enrollment period.
SEP Proof of Qualifying Life Event Form-2024
Use this form to provide proof of a qualifying life event when making account changes due to a special enrollment period.
Special Enrollment Period Quick Guide-2025
Refer to this document for information about special enrollment periods.
Special Enrollment Period Quick Guide-2024
Refer to this document for information about special enrollment periods.
Grandfathered Account Change Form
Please use the following form to help your clients change plans if they are in grandfathered plans.
Grandfathered Account Change Form-2025
Use this form to make account changes.
Grandfathered Account Change Form-2024
Use this form to make account changes.
Broker Support Documents
Broker Attestation Form
You must submit a paper attestation with each paper application.
Submit completed forms to:
- Email: kpif@kp.org
- Fax: 1-866-281-1299 (toll free)
- Attn: Kaiser Permanente for Individual and Family Plans
- Mail: Kaiser Permanente for Individual and Family Plans
- 3100 Thornton Ave. Burbank, CA 91504
- Attn: Broker Sales
- 3100 Thornton Ave. Burbank, CA 91504
Broker Support Services
For a list of KPIF telephone and online solutions, download this reference sheet.
Official logo from Kaiser Permanente Brand Center
Advertise your status as a Kaiser Permanente Authorized Agent.
Client Inquiry Form: Application Status and Billing
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.
Client Inquiry Form: Compensation
HIPAA Authorization Form
Download and save our HIPAA form.
Other Forms and Support
If you have questions, please email the Broker Services Team at KPIF@kp.org or call 1-844-394-3978.