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Small Business

Employer Forms

Consolidated Appropriations Act and Transparency in Coverage LOA

2024

Maryland small group employer application - 2024
Virginia small group employer application - 2024
Group Size Attestation Form - 2024

Employee Forms

2024

Small group employee application - 2024

Other Forms and Support

Electronic Funds Transfer (ACH) Form for small groups
Kaiser Employee Enrollment Ledger (KEEL)
Incapacitated dependent form
Declination of coverage
Payroll attestation
Broker Authorization Form (Maryland)
Broker Authorization Form (Virginia)
Dental Election Form (Maryland-Virginia)
Dental Election Form (Maryland)
Dental Election Form (Virginia)

Large Business

Employer Forms

2024

DC, MD, and VA MID/LARGE employer application for groups of 51 or more employees
English (PDF)

Employee Forms

2024

DC, MD, and VA MID/LARGE employee enrollment or change form for groups of 51 or more employees
English (PDF)

Other Forms and Support

Consolidated Appropriations Act and Transparency in Coverage LOA
Incapacitated dependents form (PDF)

Forms for all groups

Individual and Family

Application

Maryland Application - 2024
Virginia Application - 2024

SEP

SEP Guide - 2024
SEP Triggered Event Form - 2024

Other Forms and Support

Incapacitated dependent form
Learn about financial assistance by downloading this application