Forms
	Checklist Kaiser Permanente Choice Solution New Group submission checklist., 1 Page (Rev. 8-2011)
	Kaiser Permanente Choice Solution ApplicationEmployer To be completed by the Employer and Broker at initial enrollment., 4 Pages (Rev. 9/2011)
	Kaiser Permanente Choice Solution Employee Application For employees to enroll in the Kaiser Permanente Choice Solution program., 4 Pages (Rev. 10-2011)
	Kaiser Permanente Choice Solution Employee Change Request Form For effective dates 10/1/2011 to 6/1/2012 Used to update personal information or to add/cancel coverage. (not for plan or provider changes), 4 Pages (Rev. 12/2011)
	Kaiser Permanente Choice Solution Employee Enrollment Guide Provides information regarding Kaiser Permanente Choice Solution plans, benefits, employee and dependent eligibility requirements, etc. , 20 Pages (Rev. 10-2011)
	Kaiser Permanente Choice Solution Employee Health Questionnaire For effective dates 10/1/2011 to 6/1/2012 To be completed by employees in a group with only 2-14 medically enrolled employees., 2 Pages (Rev. 10/06)
	Kaiser Permanente Choice Solution Employer Change Request Form For effective dates 1/1/2012 to 6/1/2012 For the Employer to request Off-Anniversary or Renewal only changes to the group's policy., 2 Pages (Rev. 9/2011)
	Kaiser Permanente Choice Solution Full-Time Student Verification For Dental Enrollees, 1 Page (Rev. 6-10)
	Kaiser Permanente Choice Solution Owner Partner Statement 1 Page (Rev. 11/2012)
	Kaiser Permanente Employee Termination Notification Form Complete this form when there is a termination of employment, reduction of hours or loss of life. Coverage will end on the last day of the month following each event., 1 Page (Rev. 10-09)
	Kaiser Permanete Medical Claim Form Used for submission of medical Claims, 2 Pages (Rev. 02-06)
	Language Assistance Program Form Members use to request Language Assistance Services Program, allowing interpretation of services and documents into certian languages. , 2 Pages (Rev. 09-09)

Benefit Summaries
	Kaiser Permanente Benefit Summaries For effective dates 10/1/2011 to 6/1/2012 Benefit summaries for all medical plans., 7 Pages (Rev. 6/2011)

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For additional information, please contact Claremont at 800.696.4543 or info@claremontcompanies.com