Group Application Submission - Kaiser New Company Set-up for Group Benefits Full Legal Company Name*Effective Date Requested*TAX Identification Number*Are you part of an Association?*YesNoAddress (Street, City, State, Zip, County)*Type of Business of your Company?*Date your Company was Established*Contact Name for Billing*Billing Contact Phone Number*Billing Contact Email Address*Indicate Owners and the Percentages of Ownership*Previous Insurance Carrier if any; when will that plan terminate?*Worker's Compensation Carrier and Renewal Date*Is anyone on Worker's Compensation? Name & DOB*Are any former staff on Cal-COBRA or COBRA? If so, please provide details*Is anyone on disability? If so, please provide details*Is anyone out of FMLA (Family Medical Leave)? If so, please provide details.*Name of Signing Officer for this form?*Officer Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.