Kaiser

Employer Application

Census Form

Prior Coverage Affidavit

Employee Application Package for New Group
Add Employee to Existing
Group Plan

Employee Waiver

Employer Waiver

Purchaser Agreement

HRA Forms

Continuation of
Coverage
Common Law Form Dependent Verification Form
Employee forms can be faxed to our office at (303) 721-1085. Please confirm that application was received by calling (303) 721-1145. Please call with any questions regarding eligibility or waiting periods.
Plan Descriptions

HMO Plans

Health Plan Name
Office Visit Copay
Hospital Copay

Outpatient Copay

Basic HMO
$40/$60

$1000/day, max $4000

 $500
Standard HMO $30/$50 $500/day, max $2000

$250
Classic 30 $30/$40 $1000 $150
Classic 35A $30/$50 20% to $4k max $200
Classic 40 $40/$75 $1000/day, $4K max $200

Deductible Plans

Plan Name
Office Visit Copay
Deductible
Coinsurance
$30/$50
$500

20% to $2,500 max
$30/$50
$1,000
20% to $3,000 max
$30/$50
$1,200
20% to $2,500 max
$30/$50
$2,000
20% to $4,000 max
$30/$50
$2500
20% to $5,000 max
$30/$50
$3,000
20% to $6,000 max
$30/$50
$4000
20% to $8,000 max
$30/$50
$5,000
20% to $10,000 max
Health Savings Account Plans
Deductible
$1,500
0%
Deductible
$2,000
0%
Deductible
$3,000
0%
Deductible
$5,000
0%