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 Sales Representatives:

Nathan Edmondson at 206.602.3558 or Nathan.Edmondson@advprofessionals.com
Paul Baker at 206.899.1895 or Paul.Baker@advprofessionals.com
Amanda Weidman at 206.962.3583 or Amanda.Weidman@advprofessionals.com

 

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 
    with group effective dates of July 1, 2021 through June 30, 2022.

 Click Here Click Here

  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

 

 

Additional Carrier Forms

 

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

  Life/AD&D and EAP Form

 Form

 

 

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