WAHIT
takes the complexity out of employee benefits, helping small and midsized businesses purchase, access and manage competitive health insurance and other benefits — simply and cost-effectively.


 

FORMS LIBRARY

This section will allow you to access forms including Group Master Applications, Enrollment Forms, Claim Forms, Administrative Forms, and other forms.

If you have any questions, please contact the Trust Program Managers:

Nathan Edmondson at 206-602-3558 or 
Nathan.Edmondson@advprofessionals.com

Paul Baker at 206-899-1895 or Paul.Baker@advprofessionals.com


 

WAHIT Employee Enrollment Form 

 

Premera Blue Cross WAHIT Forms Employee Enrollment
& Change Form
Waiver of Coverage

  2020-2021 Employee Application 

  For enrollees of groups covered by Premera Blue Cross 
    with group effective dates of July 1, 2020 through June 30, 2021

Click Here Click Here

  2019-2020 Employee Application 

  For enrollees of groups covered by Premera Blue Cross 
    with group effective dates of July 1, 2019 through June 30, 2020

Click Here Click Here

  2018-2019 Employee Application 

  For enrollees of groups covered by Premera Blue Cross
    with group effective dates of July 1, 2018 through June 30, 2019

Click Here Click Here

  2017-2018 Employee Application 

  For enrollees of groups covered by Premera Blue Cross 
    with group effective dates of July 1, 2017 through June 30, 2018

Click Here Click Here

 

 

Additional Carrier Forms

Valid for the following effective plan years:

July 1, 2019 - June 30, 2020
July 1, 2018 - June 30, 2019
July 1, 2017 - June 30, 2018

 

Plan Description

Form

Premera Blue Cross WAHIT - Medical and Dental Forms

  Grandfathered Status Certification Form

Form

  Request for Certification of Overage Dependent

For requesting certification of an overage (25+ years) dependent. See your medical benefit booklet for more information.

Form

  *Waiver of Coverage Form

Form

  *Deductible Credit Form

Form

  PBC RX Mail Order Form

Form

  PBC RX Reimbursement Claim Form

Form

  PBC Medical/Dental Claim

Form

  *Affidavit of Domestic Partnership

Form

  Statement of Termination of Domestic Partnership

Form

 

 

Plan Description

Form

USAble Life Insurance Company Life & Disability Forms

  USAble Supplemental Life Enrollment Form

Form

  USAble Evidence of Insurability Form

Form

  USAble Attending Physician's Statement

Form

  USAble Appeal Form

Form

  USAble Beneficiary Change Form

Form

  USAble Authorization for Release of Medical Records

Form

  USAble Statement of Claim Group Accident Insurance

Form

  USAble Application for Extended Insurance Benefits

Form

  USAble Proof of Death Form

Form

  USAble Extended Life Insurance (Waiver of Premium)
  Update Form

Form

  USAble Accelerated Death Benefits Statement of Claim Form

Form

  USAble Application for Portability of Group Term Life Form

Form

  USAble Request for Conversion Form

Form

  USAble Life Insurance Release of Absolute Assignment Form

Form

 

Plan Description

Form

VSP Vision Care Inc. Forms

  VSP Vision Care Inc. Reimbursement Form

Form

Plan Description

Form

Administrative Forms

  COBRA Administration Agreement

Form

  Employer Name or Tax ID Change Form

Form

  Request for Review Form (not for medical claims)

Form

 

 

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