+---+--------------+---+-----------+---+---+---+-------------------------------+---+
| S |              |   |           | # |   | # |                               |   |
| F |              |   |           | # |   |   |                               |   |
| 4 |              |   |           | # |   |   |                               |   |
| 4 |              |   |           |   |   |   |                               |   |
| 0 |              |   |           |   |   |   |                               |   |
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| K |              |   |           |   |   |   |                               |   |
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| 6 |              |   |           |   |   |   |                               |   |
| - |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 0 |              |   |           |   |   |   |                               |   |
| 0 |              |   |           |   |   |   |                               |   |
| 1 |              |   |           |   |   |   |                               |   |
| ) |              |   |           |   |   |   |                               |   |
+---+--------------+---+-----------+---+---+---+-------------------------------+---+
| ! |              |   |           | # |   | # |                               |   |
| [ |              |   |           | # |   |   |                               |   |
| ] |              |   |           | # |   | E |                               |   |
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| 3 |              |   |           |   |   |   |                               |   |
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| 5 |              |   |           |   |   | o |                               |   |
| 5 |              |   |           |   |   | r |                               |   |
| 5 |              |   |           |   |   | m |                               |   |
| 5 |              |   |           |   |   |   |                               |   |
| 5 |              |   |           |   |   |   |                               |   |
| 5 |              |   |           |   |   |   |                               |   |
| 5 |              |   |           |   |   |   |                               |   |
| 5 |              |   |           |   |   |   |                               |   |
| 5 |              |   |           |   |   |   |                               |   |
| 5 |              |   |           |   |   |   |                               |   |
| 4 |              |   |           |   |   |   |                               |   |
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| n |              |   |           |   |   |   |                               |   |
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| h |              |   |           |   |   |   |                               |   |
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| h |              |   |           |   |   |   |                               |   |
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| . |              |   |           |   |   |   |                               |   |
| 3 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 8 |              |   |           |   |   |   |                               |   |
| 4 |              |   |           |   |   |   |                               |   |
| 7 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| 2 |              |   |           |   |   |   |                               |   |
| i |              |   |           |   |   |   |                               |   |
| n |              |   |           |   |   |   |                               |   |
| " |              |   |           |   |   |   |                               |   |
| } |              |   |           |   |   |   |                               |   |
+---+--------------+---+-----------+---+---+---+-------------------------------+---+
| * |              |   |           |   |   |   |                               |   |
| * |              |   |           |   |   |   |                               |   |
| P |              |   |           |   |   |   |                               |   |
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| b |              |   |           |   |   |   |                               |   |
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| a |              |   |           |   |   |   |                               |   |
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| d |              |   |           |   |   |   |                               |   |
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| s |              |   |           |   |   |   |                               |   |
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| s |              |   |           |   |   |   |                               |   |
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|   |              |   |           |   |   |   |                               |   |
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| a |              |   |           |   |   |   |                               |   |
| s |              |   |           |   |   |   |                               |   |
| a |              |   |           |   |   |   |                               |   |
| t |              |   |           |   |   |   |                               |   |
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| m |              |   |           |   |   |   |                               |   |
| p |              |   |           |   |   |   |                               |   |
| o |              |   |           |   |   |   |                               |   |
| r |              |   |           |   |   |   |                               |   |
| a |              |   |           |   |   |   |                               |   |
| r |              |   |           |   |   |   |                               |   |
| y |              |   |           |   |   |   |                               |   |
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| D |              |   |           |   |   |   |                               |   |
| . |              |   |           |   |   |   |                               |   |
+---+--------------+---+-----------+---+---+---+-------------------------------+---+
| * |              |   |           |   |   |   |                               |   |
| * |              |   |           |   |   |   |                               |   |
| A |              |   |           |   |   |   |                               |   |
| . |              |   |           |   |   |   |                               |   |
| T |              |   |           |   |   |   |                               |   |
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| B |              |   |           |   |   |   |                               |   |
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| P |              |   |           |   |   |   |                               |   |
| L |              |   |           |   |   |   |                               |   |
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| T |              |   |           |   |   |   |                               |   |
| E |              |   |           |   |   |   |                               |   |
| D |              |   |           |   |   |   |                               |   |
| B |              |   |           |   |   |   |                               |   |
| Y |              |   |           |   |   |   |                               |   |
| E |              |   |           |   |   |   |                               |   |
| M |              |   |           |   |   |   |                               |   |
| P |              |   |           |   |   |   |                               |   |
| L |              |   |           |   |   |   |                               |   |
| O |              |   |           |   |   |   |                               |   |
| Y |              |   |           |   |   |   |                               |   |
| E |              |   |           |   |   |   |                               |   |
| R |              |   |           |   |   |   |                               |   |
| * |              |   |           |   |   |   |                               |   |
| * |              |   |           |   |   |   |                               |   |
+---+--------------+---+-----------+---+---+---+-------------------------------+---+
|   | **     **    | * | **     ** |   |   |   | **     **                     |   |
|   |              | * |           |   |   |   |                               |   |
|   |              | - |           |   |   |   |                               |   |
|   |              | * |           |   |   |   |                               |   |
|   |              | * |           |   |   |   |                               |   |
+---+--------------+---+-----------+---+---+---+-------------------------------+---+
|   | **Purchase   |   | **E       |   |   |   | **Company Name or Trust Fund  |   |
|   | Number**     |   | nrollment |   |   |   | Name**                        |   |
|   |              |   | Unit      |   |   |   |                               |   |
|   |              |   | Number**  |   |   |   |                               |   |
+---+--------------+---+-----------+---+---+---+-------------------------------+---+
|   | **     **    | * | **     ** |   |   |   | **     **                     |   |
|   |              | * |           |   |   |   |                               |   |
|   |              | - |           |   |   |   |                               |   |
|   |              | * |           |   |   |   |                               |   |
|   |              | * |           |   |   |   |                               |   |
+---+--------------+---+-----------+---+---+---+-------------------------------+---+
|   | **Employer   |   | **        |   |   |   | **Company Address or Trust    |   |
|   | ID**         |   | Effective |   |   |   | Fund Address**                |   |
|   |              |   | Date**    |   |   |   |                               |   |
+---+--------------+---+-----------+---+---+---+-------------------------------+---+
|   |              |   |           |   |   |   |                               |   |
+---+--------------+---+-----------+---+---+---+-------------------------------+---+

<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 12%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="19"><strong>B. ENROLLMENT (check only one)</strong></td>
<td colspan="8"><strong>-- OR --</strong></td>
<td colspan="20"><strong>CHANGE (check all that apply)</strong></td>
</tr>
<tr class="even">
<td colspan="11"> New Hire Enrollment – Date of Hire:</td>
<td colspan="10">     </td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"> Add Dependent:</td>
<td colspan="7">     </td>
<td colspan="4">Event Date:</td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
<td colspan="10"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="22">Enter reason and date from Section 1B on instruction
page. Complete Sections C and F below.</td>
</tr>
<tr class="even">
<td colspan="7"> Part Time to Full Time – Date:</td>
<td colspan="14">     </td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"> Delete Dependent:</td>
<td colspan="6">     </td>
<td colspan="4">Event Date:</td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td colspan="14"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="22">Enter reason and date from Section 1C on instruction
page. Complete Sections C and F below.</td>
</tr>
<tr class="even">
<td colspan="21"> Open Enrollment</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="22"> Name Change – Complete Sections C and D</td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td colspan="14"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="22"></td>
</tr>
<tr class="even">
<td colspan="3"> Other:</td>
<td colspan="10">     </td>
<td colspan="2">Event Date:</td>
<td colspan="6">     </td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="22"> Address Change – Complete Sections C and E</td>
</tr>
<tr class="odd">
<td colspan="21"><strong>See Section 1A on reverse side for
options.</strong></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="22"></td>
</tr>
<tr class="even">
<td colspan="7"></td>
<td colspan="14"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="22"></td>
</tr>
<tr class="odd">
<td colspan="18"><strong>C. EMPLOYEE/SUBSCRIBER
INFORMATION</strong></td>
<td colspan="10"></td>
<td colspan="19"></td>
</tr>
<tr class="even">
<td colspan="18">Are you now or have you ever been a Kaiser Permanente
member? Yes No If so, what is/was your Medical Record</td>
<td colspan="10"></td>
<td colspan="19">Have you ever received care from Kaiser Premanente
within the state of California? Yes No</td>
</tr>
<tr class="odd">
<td colspan="4">Number?</td>
<td colspan="14">     </td>
<td colspan="10"></td>
<td colspan="5">Under what name:</td>
<td colspan="13">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="18"></td>
<td colspan="10"></td>
<td colspan="8"></td>
<td colspan="11">Maiden/Other</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4">    -    -      </td>
<td colspan="3"></td>
<td colspan="21">     </td>
<td colspan="2"></td>
<td colspan="11">     </td>
<td></td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4">Social Security Number</td>
<td colspan="3"></td>
<td colspan="21">Last Name</td>
<td colspan="2"></td>
<td colspan="11">First Name</td>
<td></td>
<td colspan="3">MI</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4">     </td>
<td colspan="17">Gender: M F</td>
<td colspan="25">Marital Status: Married Single</td>
</tr>
<tr class="even">
<td></td>
<td colspan="4">Date of Birth</td>
<td colspan="3"></td>
<td colspan="21"></td>
<td colspan="2"></td>
<td colspan="11"></td>
<td></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="11">     </td>
<td colspan="2"></td>
<td colspan="10">     </td>
<td colspan="3"></td>
<td colspan="8">     </td>
<td colspan="11">Employment Status:</td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="11">Preferred Language Spoken</td>
<td colspan="2"></td>
<td colspan="10">Preferred Language Written</td>
<td colspan="3"></td>
<td colspan="8">Employee ID</td>
<td colspan="11"> Working Retired</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="23">     </td>
<td colspan="3"></td>
<td colspan="11">     </td>
<td></td>
<td colspan="3">     </td>
<td></td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="23">Street Address</td>
<td colspan="3"></td>
<td colspan="11">City</td>
<td></td>
<td colspan="3">State</td>
<td></td>
<td colspan="3">ZIP Code</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5">(   )     </td>
<td colspan="3"></td>
<td colspan="9">(   )     </td>
<td colspan="2"></td>
<td colspan="26">     </td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5">Day Phone</td>
<td colspan="3"></td>
<td colspan="9">Evening Phone</td>
<td colspan="2"></td>
<td colspan="26">E-mail Address (Optional)</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="18"><strong>D. NAME CHANGE</strong></td>
<td colspan="10"></td>
<td colspan="19"></td>
</tr>
<tr class="even">
<td colspan="2">FROM:</td>
<td colspan="8">     </td>
<td colspan="6">     </td>
<td colspan="6">     </td>
<td colspan="4">To:</td>
<td colspan="8">     </td>
<td colspan="11">     </td>
<td>     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="8">Last Name</td>
<td colspan="6">First Name</td>
<td colspan="6">MI</td>
<td colspan="4"></td>
<td colspan="8">Last Name</td>
<td colspan="11">First Name</td>
<td>MI</td>
<td></td>
</tr>
<tr class="even">
<td colspan="18"><strong>E. ADDRESS CHANGE</strong></td>
<td colspan="10"></td>
<td colspan="19"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="23">     </td>
<td colspan="3"></td>
<td colspan="11">     </td>
<td></td>
<td colspan="3">     </td>
<td></td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="23">OLD Street Address</td>
<td colspan="3"></td>
<td colspan="11">City</td>
<td></td>
<td colspan="3">State</td>
<td></td>
<td colspan="3">ZIP Code</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="23">     </td>
<td colspan="3"></td>
<td colspan="11">     </td>
<td></td>
<td colspan="3">     </td>
<td></td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="23">NEW Street Address</td>
<td colspan="3"></td>
<td colspan="11">City</td>
<td></td>
<td colspan="3">State</td>
<td></td>
<td colspan="3">ZIP Code</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="47"><strong>F. LIST FAMILY MEMBERS TO BE ADDED OR DELETED
(attach additional sheet, if needed)</strong></td>
</tr>
<tr class="even">
<td colspan="5"><strong>Last Name</strong></td>
<td colspan="12"><strong>First Name</strong></td>
<td colspan="4"><strong>MI</strong></td>
<td colspan="7"><strong>Role</strong></td>
<td colspan="4"><strong>Social Security Number</strong></td>
<td colspan="6"><p><strong>Date of Birth</strong></p>
<p><strong>MM/DD/YY</strong></p></td>
<td colspan="2"><strong>Gender</strong></td>
<td colspan="3"><p><strong>Add/</strong></p>
<p><strong>Delete</strong></p></td>
<td colspan="4"><p><strong>Medical Record</strong></p>
<h4 id="number-if-known">Number if Known</h4></td>
</tr>
<tr class="odd">
<td colspan="5"><p><strong>Spouse</strong></p>
<p><strong>     </strong></p></td>
<td colspan="12" rowspan="2"><strong>     </strong></td>
<td colspan="4" rowspan="2"><strong>     </strong></td>
<td colspan="7" rowspan="2"><p>Spouse</p>
<p>Domestic</p>
<p>Partner</p></td>
<td colspan="4" rowspan="2"><strong>    -    -      </strong></td>
<td colspan="6" rowspan="2"><strong>     </strong></td>
<td colspan="2" rowspan="2"><p>M</p>
<p>F</p></td>
<td colspan="3" rowspan="2"><p>Add</p>
<p>Delete</p></td>
<td colspan="4" rowspan="2"><h4 id="section-2">     </h4></td>
</tr>
<tr class="even">
<td colspan="5"><p><strong><em>Maiden/Other:</em></strong></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="5"><p><strong>Dependent</strong></p>
<p><strong>     </strong></p></td>
<td colspan="12" rowspan="2"><strong>     </strong></td>
<td colspan="4" rowspan="2"><strong>     </strong></td>
<td colspan="7" rowspan="2"><p>Spouse</p>
<p>Domestic</p>
<p>Partner</p></td>
<td colspan="4" rowspan="2"><strong>    -    -      </strong></td>
<td colspan="6" rowspan="2"><strong>     </strong></td>
<td colspan="2" rowspan="2"><p>M</p>
<p>F</p></td>
<td colspan="3" rowspan="2"><p>Add</p>
<p>Delete</p></td>
<td colspan="4" rowspan="2"><h4 id="section-3">     </h4></td>
</tr>
<tr class="even">
<td colspan="5"><p><strong><em>Relationship:</em></strong></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="5"><p><strong>Dependent</strong></p>
<p><strong>     </strong></p></td>
<td colspan="12" rowspan="2"><strong>     </strong></td>
<td colspan="4" rowspan="2"><strong>     </strong></td>
<td colspan="7" rowspan="2"><p>Spouse</p>
<p>Domestic</p>
<p>Partner</p></td>
<td colspan="4" rowspan="2"><strong>    -    -      </strong></td>
<td colspan="6" rowspan="2"><strong>     </strong></td>
<td colspan="2" rowspan="2"><p>M</p>
<p>F</p></td>
<td colspan="3" rowspan="2"><p>Add</p>
<p>Delete</p></td>
<td colspan="4" rowspan="2"><h4 id="section-4">     </h4></td>
</tr>
<tr class="even">
<td colspan="5"><p><strong><em>Relationship:</em></strong></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="5"><p><strong>Dependent</strong></p>
<p><strong>     </strong></p></td>
<td colspan="12" rowspan="2"><strong>     </strong></td>
<td colspan="4" rowspan="2"><strong>     </strong></td>
<td colspan="7" rowspan="2"><p>Spouse</p>
<p>Domestic</p>
<p>Partner</p></td>
<td colspan="4" rowspan="2"><strong>    -    -      </strong></td>
<td colspan="6" rowspan="2"><strong>     </strong></td>
<td colspan="2" rowspan="2"><p>M</p>
<p>F</p></td>
<td colspan="3" rowspan="2"><p>Add</p>
<p>Delete</p></td>
<td colspan="4" rowspan="2"><h4 id="section-5">     </h4></td>
</tr>
<tr class="even">
<td colspan="5"><p><em><strong>Relationship:</strong></em></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="47">Dependent’s Address (if different from subscriber):
Check here if all dependents are at the address below.</td>
</tr>
<tr class="even">
<td colspan="11"><p>Name(s)</p>
<p><strong>     </strong></p></td>
<td colspan="21"><p>Address</p>
<p><strong>     </strong></p></td>
<td colspan="8"><p>City</p>
<p><strong>     </strong></p></td>
<td colspan="4"><p>State</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>Zip Code</p>
<p><strong>     </strong></p></td>
</tr>
</tbody>
</table>

I understand that, except for Small Claims Court cases and claims
subject to the Medical Appeals Procedure, any claim that I, my heirs, or
other claimants associated with me assert for alleged violation of any
duty arising out of or related to membership in Health Plan, including
any claim for medical or hospital malpractice, for premises liability or
relating to the coverage for, or delivery of, services or items,
irrespective of legal theory, must be decided by binding arbitration
under California law and not by a lawsuit or resort to court process
except as California law provides for judicial review of arbitration
proceedings. I agree to give up my right to a jury trial and accept the
use of binding arbitration. I understand that the arbitration provision
is contained in the *Evidence of Coverage.*

+--------------------------------------------------------+-------------+
| ##### Employee/Subscriber Signature                    | **Date**    |
+--------------------------------------------------------+-------------+

**FIRST COPY --** To Kaiser Permanente (CSC) **SECOND COPY** -- To be
retained by purchaser **THIRD COPY** -- **To be retained by subscriber
and used as temporary ID**

**UCI**