Get Kaiser Application Form

Completing the Kaiser Application Form online is a straightforward process that ensures you provide essential information for obtaining group health coverage. This guide will walk you through each section of the form, helping you to fill it out accurately and efficiently.

Follow the steps to fill out the Kaiser Application Form online effectively.

1. Press the ‘Get Form’ button to access the Kaiser Application Form and open it in your preferred editor.
2. Begin with Section 1, Employer Information. Input the firm’s legal name, key contact person's first and last name, and contact details including phone number and email address. Fill in the address of the location applying, and the Employer Identification Number (EIN/TIN) if applicable.
3. Indicate whether all Kaiser Permanente subscribers in your group are associated with the listed EIN/TIN by selecting 'Yes' or 'No.' Additionally, provide the Standard Industrial Classification (SIC) Code and the billing address if it differs from the applying location.
4. Complete the nature of the business section by describing your primary services and products, and indicate how many years your firm has been in business. Select the type of organization by checking all applicable boxes.
5. Move to Section 2, Prior Coverage. Specify if this application is to replace any existing group insurance and include details about any prior coverage within the last 12 months and the insurance carrier's name.
6. In Section 3, Eligibility, enter the desired effective date and specify the number of eligible full-time employees applying for coverage. Indicate the number of ineligible part-time employees and those waiving coverage.
7. Section 4 covers agreements, where you certify the number of full-time employees and agree to the premium contributions required. Ensure to read all statements thoroughly before signing.
8. In Section 5, select the desired benefits from the options presented for Kaiser Permanente plans, ensuring all choices match your group's needs.
9. Proceed to Section 6 regarding pediatric dental benefits, where you must indicate your choice of dental coverage plan.
10. Complete the Request for Coverage in Section 7, ensuring you understand all eligibility conditions and requirements for coverage.
11. Finally, in Section 8, submit your signature as the authorized company officer and include the required broker information in Section 9 before saving, downloading, printing, or sharing the filled-out form.

Start completing the Kaiser Application Form online today to ensure efficient processing of your health coverage.