Renewal Date Change Request Form

Small Business
RENEWAL DATE CHANGE REQUEST
Fax: 800-369-8010
If you would like to request a change to your renewal date, please complete the form on the next page.
Your account manager will contact you if the change is approved.
Please read the instructions and guidelines below before completing the Renewal Date Change Request form. This
request will not be processed without Kaiser Permanente’s approval. If you have questions or need further information,
please call the Customer Connection Team at 800-790-4661, option 3, or contact your broker.
GENERAL INSTRUCTIONS
1.The employer is responsible for confirming all information prior to submitting.
2.Please be aware that changes to effective date may affect your premiums and plan options.
3.Be sure to sign and date where indicated.
4.Once the form is complete, make a copy for your records.
5.All effective dates will be made in accordance with the contractual agreement between the group
(employer) and Kaiser Permanente.
RENEWAL DATE CHANGE GUIDELINES
There is no retro-processing of renewal date alignment.
Renewal month may be changed for the following accepted reasons (with prior review and approval by Kaiser Permanente management):
1.To align with the calendar year, January 1.
2.To align with another carrier’s group health plan (medical only).
Employers will be required to provide evidence of the other carrier’s coverage period and open enrollment period.
3.To align with the school year of a school district.
4.To align with a Section 125 plan.
5.Early Renewal groups only with a current December renewal date may revert to their original renewal month.
CONTACT INFORMATION
Fax: 800-369-8010
Small Business
60353019 July 2015
For more information, please contact the Kaiser Permanente
Customer Connection Team at 800-790-4661, option 3.
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Small Business
RENEWAL DATE CHANGE REQUEST
Fax: 800-369-8010
COMPANY INFORMATION
Company name
Customer ID
Street address (no P.O. boxes)
City
Office phone
Ext.
(
)
–
State
Enrollment unit
ZIP
County
Fax
(
)
–
Email
CHANGE RENEWAL DATE
Current renewal date
Requested renewal date
/
/
/
/
Group health plan carrier being offered alongside Kaiser Permanente
Requested open enrollment date
/
/
REASON FOR REQUESTING TO CHANGE RENEWAL DATE
Align with calendar year
Align with another medical carrier’s renewal date
Align with school year
Align with Section 125 plan
Revert to original renewal date (Early Renewal groups only)
SIGNATURE
I affirm that I have authority to contract with KFHP and KPIC on behalf of the group, and that by signing this form, I acknowledge that changing
my renewal date will change my contract period. I further understand that this may increase my rates and that I am responsible for the additional
premium. I understand and agree that I am waiving my right to receive a 60-day notice for my renewal.
Authorized company signer (please print name)
Title (please print)
Signature
Date
X
KAISER PERMANENTE APPROVAL*
Name (please print)
Title (please print)
Signature
Date
X
*The offer and acceptance for the early renewal is not complete until the approval is signed by a Kaiser Permanente–authorized signatory.
Small Business
60353019 July 2015
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