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You can get a personalized quote based on the information you enter below. All of the information you provide is for quoting and application purposes only and will be kept confidential.
 
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website after November 16, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website after October 30, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after November 1, 2012, when our 2013 plans and rates will be available.
The benefits and monthly rates listed are valid through December 31, 2012. If you would like to apply for these plans with a 2012 effective date, we must receive your application by December 8, 2012. Beginning January 1, 2013, the plans, benefits, and monthly rates for Kaiser Permanente for Individuals and Families plans will change.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after December 8, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after October 31, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after December 8, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process to lock in your 2012 rate.

If you would like to apply for coverage with a 2013 effective date, please come back on or after December 20, 2012, when our 2013 plans and rates should be available.
 
Thank you for your interest in Kaiser Permanente. To sign up for coverage in your area, please visit kp.org/wa/shop
 
The state of Maryland has established annual open enrollment periods during the months of January and July for applicants under the age of 19 who are seeking individual health coverage.

Outside of these open enrollment periods, a child under the age of 19 may only apply for coverage on his or her own plan due to a valid court order for health benefits for the child.

Children can enroll as dependents on family plans throughout the year.
The District of Columbia has established annual open enrollment periods during the months of January and July for applicants under the age of 19 who are seeking individual health coverage.

Outside of these open enrollment periods, a child under the age of 19 may only apply for coverage on his or her own plan due to a valid court order for health benefits for the child.

Children can enroll as dependents on family plans throughout the year.
The state of Colorado has established annual open enrollment periods during the months of January and July for applicants under the age of 19 who are seeking individual health coverage.

Outside of those periods, single-subscriber coverage is available only in the case of a qualifying event: birth or adoption; marriage or dissolution of marriage; death of a policyholder; loss of employer-sponsored insurance; loss of eligibility under the Colorado Medical Assistance Act or the Children's Basic Health Plan; entry of a valid court order mandating that a child be covered; or loss of other existing coverage for any reason other than fraud, misrepresentation, or failure to pay premium. You may enroll your child at any point during the year within 30 days of a qualifying event.

Children can enroll as dependents on family plans throughout the year.
Thank you for considering Kaiser Permanente. We currently do not offer health care coverage in your area. To find the coverage you need, please visit your state’s Health Insurance Marketplace.

Thank you for considering Kaiser Permanente. Kaiser Permanente will be offering our plans only through DC Health Link dchealthlink.com. As a Washington, D.C. resident, you must purchase your health plan through the DC Marketplace.

For more information on our plans or how to apply through DC Health Link, call us at 1-800-488-3590 TTY: 711. We’ll be happy to guide you through the process.

The ZIP code you entered is not within a Kaiser Permanente Individual and Family Plans service area.
You selected "Yes". Those of you who are entitled to Medicare Part A or enrolled in Medicare Part B can’t enroll in an individual and family plan. Please visit kp.org/medicare to learn more about your Medicare plan options or apply for coverage.
 
Your Information *Required
Your Information
* ZIP Code:
State:
    County:
Check Your Eligibility
* Are you or any dependent you’re applying for either entitled to Medicare Part A or enrolled in Medicare Part B?
If you selected "Yes," those of you who are entitled to Medicare Part A or enrolled in Medicare Part B can’t enroll in a KPIF plan. Please visit kp.org/medicare to learn more about your Medicare plan options or to apply for Medicare coverage. If you selected "Yes," those of you who are entitled to Medicare Part A or enrolled in Medicare Part B can’t enroll in an individual and family plan. Please visit kp.org/medicare to learn more about your Medicare plan options or to apply for Medicare coverage. If you selected "Yes," those of you who are entitled to Medicare Part A or enrolled in Medicare Part B can’t enroll in an individual and family plan. Please visit kp.org/medicare to learn more about your Medicare plan options or to apply for Medicare coverage.
Tell Us When You’re Applying
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Select 1 Option:
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†If you’ll be getting federal financial assistance, don’t use this application. We can help you apply through Connect for Health Colorado.

For help, contact us at 1-800-494-5314 or contact your broker.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
Select the triggering event (or qualifying life event)
* If you selected “A special enrollment period,” choose the qualifying life event (proof of eligibility is required):
* If you selected “A special enrollment period,” choose the qualifying life event (proof of eligibility is required):
For more information on qualifying life events, please visit kp.org/specialenrollment or call 1-800-494-5314.
Select the triggering event (or qualifying life event)
* If you selected “A special enrollment period,” choose the qualifying life event (proof of eligibility is required):


*If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
†If you’ll be getting federal financial assistance, don’t use this form. We can help your apply at healthcare.gov
*If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
†If you’ll be getting federal financial assistance, don’t use this form. We can help your apply at marylandhealthconnection.gov
*If your qualifying life event is “Loss of health care coverage,* the date of the qualifying life event is the last day of full coverage under your prior plan. If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
If you are applying during a special enrollment period, please enter the date of your qualifying life event.
* If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to verify loss of minimum essential coverage.
† If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at CoveredCA.com.
* If your qualifying life event is loss of KFHPNW coverage, we may review your prior membership records to establish eligibility.
† If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at wahealthplanfinder.org.
* If your qualifying life event is loss of KFHPNW coverage, we may review your prior membership records to establish eligibility.
† If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at healthcare.gov.
*If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
†If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at healthcare.gov.
*If your qualifying life event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
†If you’ll be getting federal financial assistance, do not use this form. We can help you apply at healthcare.gov.
Qualifying life event date
* Date of your qualifying life event
Effective Date:
If you are applying by paper
Click the "Paper application" link on the left to download the file. Fill out the application as instructed, and mail or fax the form.
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Proof of Qualifying Life Event Form
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Do you qualify for a special enrollment period?

In general, you can only change or apply for health care coverage during the yearly open enrollment period. But if you have a qualifying life event, you may be able to change or apply for coverage for a limited time before or after this event occurs. This is called a special enrollment period.

To qualify for a special enrollment period, you must:
  • Have a qualifying life event
  • Have proof of your life event
  • Apply within 60 days of your life event. For some qualifying life events, you can enroll before the date of your event.
Examples of these types of qualifying life events include:
  • Getting married
  • Having a baby
  • Losing coverage because you lost your job
The special enrollment period generally lasts 60 days from the date of your qualifying life event.
For example, if you have a baby on June 1, you have 60 days — or by July 30 — to apply for coverage.

What if my life event happens during open enrollment?

Even if your qualifying life event happens during open enrollment, you’ll still have a special enrollment period.

What if I know about my life event in advance?

If your qualifying life event is a loss of coverage that you know about in advance, you may be able to apply for new coverage ahead of time. In this case, you have 60 days before and 60 days after the event to apply.

For more information on qualifying life events and start dates, visit kp.org/specialenrollment.
2014 open enrollment & start dates

Open enrollment is October 1, 2013, through March 31, 2014. If you submit your completed application today, your coverage may start on the date above. To make sure your coverage starts on the date you want, please make sure your completed application is received by the following:


For All regions(Except Washington)
  • For Colorado: Dec. 23 2013, for coverage starting Jan. 1, 2014
  • Dec. 15 2013, for coverage starting Jan. 1, 2014
  • Jan. 15 2014, for coverage starting Feb. 1, 2014
  • Feb. 15 2014, for coverage starting Mar. 1, 2014
  • Mar. 15 2014, for coverage starting Apr. 1, 2014
  • Mar. 31 2014, for coverage starting May. 1, 2014
  • For Oregon: Feb. 17 2014, for coverage starting Mar. 1, 2014
  • For Oregon: Mar. 17 2014, for coverage starting Apr. 1, 2014
  
 

We will confirm the start date in your acceptance letter. If there is a delay in processing your application, we’ll select the next available start date.
Note: Effective dates for applicants under the age of 19 may vary.  
The earliest your coverage will begin is the first or 15th of the month following receipt of a completed application and first month's premium. Coverage will not be back dated.
For California Residents Only: You may get a quote and apply for individual coverage. If family members want to get a quote or apply for coverage, each family member will need to fill out their quote and/or application separately.
For Hawaii Residents Only: You may get a quote and apply for individual coverage. If family members want to get a quote or apply for coverage, each family member will need to fill out their quote and/or application separately.
Who is going to be covered?

Is this a child-only quote?

 
Person(s) Covered *Date of Birth Gender Smoker
* Primary Applicant
Spouse
Domestic Partner
Child
Child
Child
A domestic partner is a person legally recognized as your domestic partner in a valid Certificate of Registered Domestic Partnership issued by the state of Oregon.
*If you are 65+ years of age and Medicare eligible, or are under age 65 and entitled to Medicare on the basis of Social Security disability, call 1-866-949-5142 for information about our Kaiser Permanente Medicare Plus plans.
**Partner means a Domestic Partner, and, with respect to District of Columbia applicants only, it also includes a Legal Partner (any same-sex relationship recognized as valid by any other jurisdiction, such as civil unions). This definition of Partner applies whenever this term is used in this application.
**The term "Partner" includes both a Domestic Partner, and a Legal Partner (any same-sex relationship recognized as valid by any other jurisdiction, such as civil unions) and applies whenever used in this application. A copy of your certificate of domestic partnership or a domestic partner affidavit must accompany the application prior to the application processing.
*The term "Partner" means a Domestic Partner, whenever used in this application.
 
60590108 Colorado January 2018
60977708 Colorado January 2019
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