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.
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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 Sales Representatives: |
WAHIT Employee Enrollment Form
Premera Blue Cross WAHIT Forms | Employee Enrollment & Change Form |
Waiver of Coverage |
2021-2022 Employee Application For enrollees of groups covered by Premera Blue Cross |
Click Here | Click Here |
2020-2021 Employee Application For enrollees of groups covered by Premera Blue Cross |
Click Here | Click Here |
Additional Carrier Forms
Plan Description |
Form |
Premera Blue Cross WAHIT - Medical and Dental Forms |
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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 |
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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) |
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 |
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VSP Vision Care Inc. Reimbursement Form |
Form |
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