Group Health Insurance Application

Please complete the entire request for application.

You may call at (888) 492-7245

Business Name: 
When would you like coverage to start?
How many employees do you anticipate enrolling?
Principal Owner/Corporate Officers
1. Name:    Title:
2. Name:    Title:

California Group Coverage Forms

Employee Enrollment Application
New Group Application and Enrollment Provisions (English)
Proprietor/Partnership/Corporate Officer Form
Declination of Coverage

Or you may call (888) 492-7245

Enrollment Provisions
As an employer interested in offering Kaiser Permanente coverage, you should be aware of the following provisions:



  • Employees and their family dependents (spouse, unmarried children to age 19, and students to age 24) are eligible for coverage if they live within our service area.

Annual Open Enrollment

  • Once a year, employees must be given the opportunity to change plans or add dependents not previously enrolled.
  • Employees and/or dependents who do not enroll when first eligible must wait until the annual open enrollment period to enroll unless enrollment is due to new dependents or loss of other coverage.

Subscriber Minimum

  • Your company qualifies for our small group coverage if you have had at least 2 and no more than 50 full-time (at least 20 hours per week)
  employees for at least 50% of the previous calendar quarter from the date of sale.  Eligibility is defined as those living in the  Service Area as defined below.
California Enrollment Guidelines: Minimum of 1 enrolled, with at least 70% of eligible employees covered by an group health plan (I.e.  through their employer or their spouse's).

Employer's Contribution and Payroll Deduction

  • Your contribution must be at least 50% of the Kaiser Permanente rate for single subscribers. Any part of the cost not paid by your company must be collected from the employees through payroll deductions.

Full-Month Coverage

  • Kaiser Permanente membership begins on the first day of the month following the waiting period that you specify and continues through the end of the termination month.