DocuSign Envelope ID: 52A65CE4-BBCB-45C5-90E8-1D7A4330FA36

Dasher Quarterly Healthcare Stipend Verification Form

Your health matters. That’s why we’re excited to offer a quarterly stipend to help you offset healthcare costs. To
make sure you qualify, please fill out the required fields in this form and click “FINISH” to submit the form. Once
submitted, if you need to update or make changes to the form, please resubmit using the original link sent on 1/1/24.

Keep in mind: Your information will only be used to confirm you’re actively enrolled in a qualifying healthcare program
to determine your eligibility for this stipend. For information about how DoorDash safeguards your data, review the
DoorDash Dasher Privacy Policy.

Your Information
First name: Jorge
______________ Email on your DoorDash account: jorgecuellar53@yahoo.com
_______________________________
Last name: Cuellar
______________ 510-734-7129
Phone Number on your DoorDash account: _______________________

Your Healthcare Information

Insurance Company / Health Plan: Kaiser Permanente

Select ALL months in which you had one or more days of qualifying healthcare coverage:
X October 2023
X November 2023
X December 2023

Types of coverage:
X Covered California Insurance (NOT sharing data) – On-Exchange
My insurance is through Covered California OR my insurance card has the Covered California logo,
and I did NOT opt in to share my health insurance coverage info with DoorDash. Learn More
Not sure if you opted-in? Sign into your Covered CA account, and under "Tax Forms & Other
Important Documents,” scroll to "Household Sharing Summary" to see if you are sharing your coverage info with us.
Upload your Covered California Form, which is accessible via the "View Proof of
Coverage Forms" button on your Covered California Account Home page:
Covered California Insurance (sharing data) – On-Exchange
My insurance is through Covered California OR my insurance card has the Covered California logo,
and I opted to share my health insurance coverage info with DoorDash before January 1, 2024.
Not sure if you opted-in? Sign into your Covered CA account, and under "Tax Forms & Other
Important Documents,” scroll to "Household Sharing Summary" to see if you are sharing your coverage info with us.

Non-Covered California – Off-Exchange

My insurance is not through Covered California, but my plan meets the ACA requirement for
minimum essential coverage and is NOT Medicare, Medicaid, or provided through my Employer.
My insurance card does NOT have the Covered California logo.

Please confirm the following:

I confirm that I’ve provided the email and phone number used for logging in to my DoorDash account. Failure to
provide the email and phone number on my DoorDash account will result in my stipend request being denied.

I confirm that the months of coverage I provided are correct and will match the uploaded documents.

I am the subscriber of the health insurance plan being uploaded.

I understand that submitting inaccurate or fraudulent information violates the Dasher Deactivation Policy and
could result in my DoorDash account being deactivated.
DocuSign Envelope ID: 52A65CE4-BBCB-45C5-90E8-1D7A4330FA36