Washington Small Group Employer Application

2020 Washington Small Group EMPLOYER APPLICATION

All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest, 500 NE Multnomah St, Portland, OR 97232.

1 ABOUT BUSINESS

Legal business name

Doing business as (DBA)

Physical street address (no P.O. boxes) City State ZIP County

Phone Fax

Type of business Corporation Sole proprietorship Partnership Limited liability company (LLC) Other

In business since Federal tax ID (EIN) number NAICS code Website

Workers' compensation Yes, my company has workers’ compensation Pending

If Yes or Pending, name of carrier Policy #

Exempt from providing workers' compensation for the following reason:

2 OTHER MEDICAL COVERAGE

Does your company or affiliated company(ies) have or has it ever had group coverage directly through Kaiser Permanente? Yes No Group ID Company name

Does your company currently have active group health coverage? Yes No Name of carrier Renewal date

Will you be offering another carrier’s small group health plan, alongside Kaiser Permanente, to your employees? Yes No Name of carrier Number of employees enrolled

3B EMPLOYEE COUNT

Total employees Authorized company signer’s initials

Group number Requested effective date

3A EMPLOYER ELIGIBILITY

Is your company affiliated with another company and eligible to file a combined tax return? Yes No

Company name Affiliate Subsidiary

Address City State ZIP

Federal tax ID number Phone

3C ELIGIBLE AND ENROLLING EMPLOYEES

Total number of eligible employees Authorized company signer’s initials

Total number of enrolling employees Authorized company signer’s initials

If you’re covering only a certain class of employees, specify the class(es):

Total number of employees eligible for Medicare coverage

Hours per week employees must work to be eligible for coverage

Employee only coverage? Yes No

4 DOMESTIC PARTNER COVERAGE

Do you wish to offer Domestic Partner Coverage (non-state-registered)? Yes No

5 CONTINUATION COVERAGE

Did your company employ 20 or more employees for at least 50% of the workdays of the preceding calendar year, making it subject to COBRA? Yes No

6 ERISA STATUS

Is your company subject to ERISA? Yes No

7 MEDICARE SECONDARY PAYOR STATUS

Are you subject to TEFRA? Yes No

8 EMPLOYER PREMIUM CONTRIBUTION

Percentage of the premium is based on the following Lowest plan offered All plans offered Specific plan offered

Employer contribution (50%–100%) % per employee % per dependent (optional)

Employer contribution (fixed $) $ per employee $ per dependent (optional)

9 CONTRACT SIGNER INFORMATION

First name MI Last name Title

Street address (mailing) City State ZIP

Office phone Ext. Fax Cellphone

Email Correspond by Email Mail

10 BILLING CONTACT INFORMATION

Check here if same as contract signer.

First name MI Last name

Street address City State ZIP

Office phone Ext. Fax Cellphone

Email Correspond by Email Mail

11 SELECT BENEFIT OFFERINGS

Medical/Vision plan selections:

Dental plan selections:

1st plan

2nd plan (if bundled)

Pediatric dental plan

HSA/HRA/FSA selection(s)

12 MEDICAL PLANS

Traditional plans:

Deductible plans:

High deductible health plans:

Added Choice® deductible plans:

PPO Plus® deductible plans:

13A ADULT DENTAL PLAN OPTIONS (AGE 19 AND OLDER)

13B PEDIATRIC DENTAL PLAN OPTIONS (AGE 18 AND YOUNGER)

Dental choice PPO

13C FAMILY DENTAL PLAN OPTIONS

Dental choice (PPO)

14 IMPORTANT INFORMATION – PLEASE READ CAREFULLY

This is an application for coverage only. No contract for coverage will exist until Kaiser Foundation Health Plan of the Northwest (KFHPNW) has completed its review and communicated to the business applicant or the applicant’s broker that the application has been accepted and a group health plan contract/group policy will be issued.

15 AUTHORIZED AGENT/BROKER OF RECORD FOR KAISER PERMANENTE

Agent name License number

Phone Fax Cellphone

Email

Firm name EIN/TIN Kaiser Permanente broker firm ID

Street address City State ZIP

16 AGREEMENT AND SIGNATURE

Authorized company signer (please print name) Title (please print)

Signature required for all Kaiser Permanente Plans Date