Kaiser Permanente Washington (formerly Group Health Cooperative) Application Agreement

Sign the application agreement

Important: All applicants and dependents 18 and older must read, sign, and date below. If the primary applicant is a child under 18, then his or her parent or legal guardian must sign. By signing, the parent or legal guardian agrees to be responsible for paying all premiums, copays, coinsurance, and deductibles for all the applicants listed on this application. A copy of your agreement with your signature is as valid as the original. If signatures are missing, we will cancel the application. If there are more than 5 dependents 18 and older signing, please attach a copy of this page with the additional signatures.

-I understand that KFHPWA will rely on the information provided in this application. If any information is found to be fraudulent or intentionally misrepresented, then KFHPWA may choose to terminate coverage back to the coverage effective date.

-It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.