Oregon / SW Washington

Individuals and families (KPIF)

Accessing the right forms for your clients is easy. Below are commonly used forms for the KPIF line of business.

KPIF Applications and Account Change Forms

These forms can be used to apply for individual or family coverage provided by Kaiser Foundation Health Plan of the Northwest. Individuals can also apply online at buykp.org/apply.

Special Enrollment

Outside of the open enrollment period, individuals can enroll or change coverage if they have experienced a qualifying life event (QLE). Examples of qualifying life events include getting married, having a baby, or losing coverage due to the loss of a job. For more information regarding special enrollment periods, please visit kp.org/specialenrollment.

Special Enrollment Qualifying Life Event Form

2024 English (PDF) | 2024 Spanish (PDF)
2023 English (PDF) | 2023 Spanish (PDF)

Special Enrollment Guide

2024 English (PDF) | 2024 Spanish (PDF)
2023 English (PDF) | 2023 Spanish (PDF)

Other Forms and Support

Agent of Record Form

Authorization for insurance agent/producer to act on behalf of an applicant.

Individuals and families (KPIF)

KPIF Applications and Account Change Forms

Oregon KPIF Application

Washington (Clark & Cowlitz Counties) KPIF Application

Oregon KPIF Account Change Form

Washington (Clark & Cowlitz Counties) KPIF Account Change Form

Special Enrollment

Special Enrollment Qualifying Life Event Form

Special Enrollment Guide

Other Forms and Support

Agent of Record Form

Oregon Non-Tobacco Declaration Form

Washington Non-Tobacco Declaration Form

KPIF Broker Support Services Flier

Summary of Benefits and Coverage (SBC) for KPIF Plans

Small Business

Employer Forms

Small Group Checklist

Small Group employer application (OR)

Small Group employer application (WA)

Group profile form for renewing groups (OR)

Group profile form for renewing groups (WA)

Group profile form for new groups (OR)

Dental employer application (OR)

Dental employer application (WA)

Employer Administrative Changes form

Change In Ownership form

Small Group Late Submission form

Census Spreadsheet

Employer Attestation Declination of Coverage (OR)

Employer Attestation Declination of Coverage (WA)

Electronic Transfer for Initial and Recurring Payments Form

Employee Forms

Small Group employee enroll/change form—fillable (OR)

Small Group employee enroll/change form—fillable (WA)

Additional Dependent Form – Small Group (OR)

Additional Dependent Form – Small Group (WA)

Employee Declination of Coverage (OR)

Employee Declination of Coverage (WA)

Waiver of group insurance for Small Business Groups (OR)

Waiver of group insurance for Small Business Groups (WA)

Other Forms and Support

Consolidated Appropriations Act and Transparency in Coverage LOA

Employee Assistance Program (EAP) from TELUS Health:

Large Business

Employer Forms

Large Group employer application (OR)

Large Group employer application (WA)

Consolidated Appropriations Act and Transparency in Coverage LOA

New and Renewing Large Group Application

Enrollment Application Certification Checklist for Washington State

Employee Assistance Program (EAP) from TELUS Health:

Employee Forms

Employee Enrollment/Change Form — Large Group (OR)

Employee Enrollment/Change Form — Large Group (WA)

Additional Dependent Form — Large Group (OR)

Additional Dependent Form — Large Group (WA)