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Owner/Officer Eligibility Statement

    https://www.wordandbrown.com/getmedia/47021dd3-45d1-4d9c-9bb7-d2d454c160aa/2020-Kaiser-SG-Proprietor_Partner_Corporate_Officer_Statement.pdf
    Note: Kaiser Permanente reserves the right to ask for additional documentation as circumstances warrant. If you’re a proprietor, partner, or corporate officer who’s not listed on the DE 9C (Quarterly Contribution Return and Report of Wages), please complete this form to establish your relationship to the company referenced below. 3 READ AND ...

Small business forms - Kaiser Permanente Brokers

    https://account.kp.org/broker-employer/resources/!ut/p/z1/hZDdasMwDIWfJpdGypLGdu_skKQ_M6UtrJlvhhuyLJA4ITMbffuZtvSui0BwhD4dCYGGErQ1P21jXDtY0_n6XScfaSFWMX1FZErlKI4rWVDFXlBF8AanOUT7Nj4JgX5eX5GHQ7GPJa6p2m2zA4u8ugP_eGxAN91wvh385dy4DDDA33GsButq6yqf9RQgaDO5tupqKGmWcrmgSBKeZiQMs5iwRHDCF3kSsTCXTPJZt6lu_J-gTMUselPW9H735zD13zD2OV8Tfb5EXfMHFDFCkg!!/dz/d5/L2dBISEvZ0FBIS9nQSEh/
    Owner/Officer Eligibility Statement (PDF) — Your clients can use this form to provide proof of eligibility for proprietors, partners, and corporate officers not appearing on their DE-9C form. (Updated 9/27/19)

Kaiser Permanente Enrollment Kit Word & Brown

    https://www.wordandbrown.com/Landing-Pages/Broker-Resources/Documents-Forms/Kaiser-Permanente-Enrollment-Kit
    Enrolling owners/officers are eligible for coverage when at least one W-2 employee (it doesn’t include a sole proprietor or their spouse, and a partner or their spouse) has a minimum of 6 weeks of eligible payroll. The W-2 employee can enroll or waive valid group coverage.

California - Kaiser Permanente Health Care

    https://account.kp.org/business/forms-and-documents/california
    Employers can use this form to transfer employee information to the Declination of Coverage form. Owner/officer eligibility statement (PDF) Use this form to provide proof of eligibility for proprietors, partners, and corporate officers not appearing on the DE 9C. Additional tax forms may be requested. Participation and contribution attestation ...

Proprietor Partner CorporateOfficer Form

    https://www.dvins.com/download%20files/Proprietor_Partner_CorporateOfficer_Form.pdf
    Proprietor/Partner/Corporate Officer Form (If not established on DE-9c) To establish the relationship between proprietors, partners, and/or corporate officers to the below referenced company, please complete and return this form. I attest that, although my name does not appear on the DE 9c wage report of the below-named

ELIGIBILITY STATEMENT Sole Proprietor, Partner, or ...

    https://www.sutterhealthplus.org/pdf/sutter-health-plus/shp-sole-proprietor-form.pdf
    Name of Sole Proprietor, Partner or Corporate Oficer (please print) Title (please print) Signature of Sole Proprietor, Partner or Corporate Oficer Date . Groups with less than 5 employees enrolled must provide proof of eligibility for each owner as requested. Fax or email completed form to: Fax: 916-736-5418 . Email: [email protected] E-18-043

PARTNER’S, SOLE PROPRIETOR’S OR CORPORATE OFFICER’S …

    https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.floir.com%2FsiteDocuments%2FOIR-B1-1562.DOC
    Partner’s, Sole Proprietor’s or Corporate Officer’s Printed Name Title Signature (Attach copy of proof of identification) Date Office of Insurance Regulation Property & Casualty Forms and Rates. OIR-B1-1562. REV. 07/2003

National leaders Kaiser Permanente

    https://about.kaiserpermanente.org/who-we-are/leadership-team/national-leaders
    Kaiser Permanente’s leadership team is composed of executives who are committed to making strides in total health for our members.

CORPORATE OFFICERS, MEMBERS, MANAGERS, PARTNERS, …

    https://www.sls-ins.com/wp-content/uploads/2017/12/Officer-Election-Rejection-Form.pdf
    Depending on your respective State Insurance or Labor Code, an Officer, Partner, Member, Manager, Sole Proprietor or Other individual may be required or permitted to either ELECT or REJECT workers compensation coverage. This form provides documentation of your decision as your state has not promulgated a form for this purpose.

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