Health Insurance Continuation

This information was provided by Anna, our insurance broker at Thornton & Associates.

If the terminated employee elects State Continuation of his or her health insurance:


 * On our billing statement:


 * 1) Circle the employee(s) eligible for State Continuation.
 * 2) Write "6 month State Continuation" next to the terminated employee's name.
 * 3) Write the date of employee(s) terminated employment.
 * 4) Write your name and phone # at the bottom of the page ("Reported by" section)
 * 5) The terminated employee must complete & sign an enrollment application/ change form. ("State Continuation" written on the top) & submit their monthly premium to John's Market.
 * 6) FAX the enrollment form to: (503) 813-4426 and (503) 246-3816
 * 7) Mail the original signed Enrollment Application to: Kaiser Permanente NW/ Membership Administration / PO Box 921008/ Fort Worth TX 76121-0008

If the terminated employee DECLINES State Continuation:


 * On our billing statement:


 * 1) Line out the employee(s) to be terminated.
 * 2) Write, "Please terminate coverage effective ?/?/05*" next to the terminated employee's name. (*coverage is month to month; if the last day of employment was 5/13/05 then the last day of coverage is 5/31/05)
 * 3) Write the premium amount that applies in the "Adjustment" column
 * 4) Record the total at the bottom of the page and pay the appropriate amount.
 * 5) Write your name and phone # at the bottom of the page ("Reported by" section)

Note: Employee has options through Kaiser directly. For information, the employee may call 813-2000. (All employees are eligible for state continuation through Kaiser regardless of length of employment).