| Applications & Forms |
Form # |
Effective |
 |
Affidavit of Domestic Partnership |
KP 554 |
04/06 |
|
Agent Agreement |
CA 0130 |
03/06 |
|
AIG Licensing Form |
AGAC0031TPA |
09/02 |
|
Business Associate Agreement |
CA 0125B |
03/06 |
|
Change Request - Employee |
KP 0500 |
03/06 |
|
Change Request - Employee (Spanish) |
KP 0500SP |
03/06 |
|
Changes Flyer |
KP5337 |
11/06 |
|
Choice Brochure |
KP0190 |
01/07 |
|
Cobra Cancelation Notice |
KP 0425 |
02/07 |
|
COBRA Member Cancelation Notice |
KP0425 |
02/07 |
|
Direct Deposit Authorization |
CA 5218 |
06/06 |
|
Disabled Dependent Certification |
KPIC-6 |
03/06 |
|
Employee Application |
KP0310 |
10/06 |
|
Employee Application (Spanish) |
KP 0315 |
10/06 |
|
Employee Change Request Form |
KP0500 |
03/06 |
|
Employee Change Request Form |
KP 0500B |
02/07 |
|
Employee Change Request Form (Spanish) |
KP 0500SP B |
02/07 |
|
Employee Enrollment Application |
KP0310 |
01/07 |
|
Employee Health Questionnaire |
KP0568 |
06/06 |
|
Employer Application |
KP0201 |
10/06 |
|
Employer Application |
KP0201 |
01/07 |
|
Employer Change Request Form |
KP564 |
07/06 |
|
Employer Change Request Form |
KP 0564A |
02/07 |
|
Employer Termination Notice |
KP420a |
01/07 |
|
Health Questionaire |
KP 0568 |
06/06 |
|
Health Questionaire (Spanish) |
KP 0568SP |
08/06 |
|
Kaiser Permanente Emergency Medical Claim Form |
98700 |
04/04 |
|
New Hire Quote Request |
KP 0170 |
03/06 |
|
Open Enrollment Change - Employee |
KP0311 |
03/06 |
|
Open Enrollment Change Request Form (Spanish) |
KP 0311SP |
10/06 |
|
Owner / Partner Statement |
KP0202 |
01/07 |
|
Owner / Partner Statement |
KP 0202 |
01/07 |
|
Proposal Request |
KP120a |
10/06 |
|
Student Verification |
KP 0206 |
02/00 |
| Benefits & Guides |
Form # |
Effective |
|
2 New High Deductible Health Plans (HDHP) |
KP5337 |
11/06 |
|
Administrator Handbook |
KP 0230 |
12/06 |
|
Benefit Summaries |
KP 5234 |
07/06 |
|
Benefit Summaries |
KP 5234b |
11/06 |
|
Benefit Summaries |
KP5234 |
01/07 |
|
Broker Licensing |
KP 0100 |
03/06 |
|
Commission Schedule |
CA 0140 |
02/06 |
|
Dental Rate Summary |
NA |
01/07 |
|
Dental Rate Summary 1/1/07 - 6/1/07 |
NA |
10/06 |
|
Employee Enrollment Guide |
KP0300 |
07/07 |
|
Employee Enrollment Guide (Spanish) |
KP0300SP |
07/07 |
|
Employee Health Questionnaire |
KP0568A |
10/06 |
|
Optional Benefits Guide - Employer |
KP 0220 |
04/06 |
|
Owner / Partner Statement |
KP0202 |
10/06 |
|
Privacy Statement |
CA 0125 |
03/06 |
|
Program Highlights |
KP5356 |
10/06 |
|
RAF Guidelines |
KP6009a |
10/06 |
|
RAF Guidelines |
KP6009A |
02/07 |
|
Rate Guide (6.1.06) |
NA |
07/06 |
|
Rate Guide (7.1.06 - 12.1.06) |
NA |
07/06 |
|
Sales Brochure |
KP0190 |
11/06 |
|
Small Group Disclosure |
KP 0240 |
06/06 |
|
Small is Big Bonus |
KP2291 |
04/07 |
|
Standard Rate Summary |
NA |
01/07 |
|
Standard Rate Summary - 1.1.07 - 6.1.07 |
NA |
10/06 |
|
Submission Checklist |
KP 0261 |
03/06 |
|
Total Replacement Reward |
KP3252 |
04/07 |
|
Underwriting Guidelines |
KP 6009 |
03/06 |
|
Underwriting Guidelines |
KP6009 |
10/06 |
|
Zip Code Rate Guide |
NA |
10/06 |
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