Cobra Enrollment Form - Kaiser Permanente Brokers and Employers

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.
Purchaser/Enrollment Unit
Employer Signature/Date
Reason for COBRA Enrollment
Enrollment Information
Please check the reason for
enrollment and complete the
maximum months of coverage.
NOTE: If requesting a transfer
of an existing COBRA account
from another carrier to Kaiser
Permanente, you must indicate
the qualifying event for the
initial COBRA enrollment.
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 ______
Reason for loss:  Marriage  Divorce or legal separation  Death of subscriber  Reached maximum age ____
 Subscriber’s Medicare entitlement  Other ______
Transfer of existing COBRA account from another carrier to Kaiser Permanente
Carrier’s Name & Telephone Number _______________________________________________________________
Policy Number _________________________ Policy Term Date _________________________
Original initial COBRA enrollment reason ______________________________
Original initial COBRA coverage start date _______________
Maximum months of coverage _____________
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.)
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
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
partner (if
Name: (Last/First/MI)
Social Security number
Date of birth
 Spouse
 Domestic partner
 Child
 Student
 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
(Excluding KPIC PPO, KPIC OOA, and KPIC Dental Plans)
Guidelines for completing this form
1. Complete all applicable fields on the form. Use only dark
blue or black ink. Please print clearly.
2. Complete and sign this enrollment form. The subscriber
(employee) must sign the form; or, in the case of spouse
domestic partner (if eligible) or dependent making their
own individual election, such individual must sign the
form. With respect to an individual under the age of 18,
the parent or legal guardian must sign the form. Include
information on all dependents to be covered.
3. The subscriber (employee) on the group coverage
account is not required to be enrolled in the COBRA
account. If the employee does not enroll in COBRA,
please specify who the new subscriber on the account
should be in the “Subscriber Enrollment Information”
section of the form.
4. Your spouse (or domestic partner, if eligible) or
dependent children are eligible to enroll if they were
covered under your Kaiser Permanente group plan.
Dependents may be added only during open enrollment,
or under the special enrollment provisions of HIPAA
(Health Insurance Portability and Accountability Act of
5. Do not submit payment with this form. Your former
employer will instruct you on how to make your
6. For enrollment in a COBRA account, check with your
former employer as to where to submit the form. Do not
mail or fax it to us.
7. Be sure to include the Social Security Numbers of any
members who are, or have ever been, Kaiser
Permanente members. We will use this number to
ensure that they retain the same Medical Record Number
that they may have been assigned in the past.
8. Only new members will receive an ID card. Existing
members will not receive new cards. Please continue to
use your existing card.
9. If you are transferring your existing COBRA account from
another carrier to Kaiser Permanente during Open
Enrollment, be sure to include the original reason why
you were initially eligible for your COBRA coverage, and
identify your other carrier’s name and your original start
CSC May-2011
Please read instructions. Both the employer and the employee must complete fields on
this form to request enrollment in a Kaiser Permanente group COBRA account.