Health Insurance Continuation

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

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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).