Enrollment Checklist (VA)
Use the following checklist to compile the enrollment materials for employer-sponsored group coverage with Kaiser Permanente.
Download the Employee and Employer applications using the links below. Once completed, then upload all required documents to our secure site: Click here to send files securely.
☑ Employee Enrollment Form / 2018 (“VA-SG-KFHP-KPIC-EN”). The employee must sign in Section F, and the employer must sign in Section G. If an employee is waiving coverage, check “Waiver” on page 1, complete Section A, and complete and sign Section C.
☑ Employer Application (“VA-SG-GRP-APP”); be sure to sign where indicated in Section 7.
☑ Wage & Tax report (VEC 20/21) for your business – Employer’s quarterly payroll report or two most recent payroll register by professional payroll company. If you don’t have a Wage & Tax Report, supply a copy of your Schedule C or K1.
☑ Scanned copy of a check for the first month’s premium, payable to Kaiser Permanente.
☑ Mail original check to:
Employee Benefits Corporation of America
1410 Spring Hill Road STE 150
McLean, VA 22102
Attention: Wendy Zindler