WAHIT Employer Forms Library

Plan Description

Form

Premera Blue Cross Forms - NOT Located in Clark County

NEW! 2011-12 Employee  Application  
For enrollees of groups covered by Premera Blue Cross with group  effective dates of July 1, 2011 through June 1, 2012. 

Spanish

2010-11 Employee  Application  
For enrollees of groups covered by Premera Blue Cross with group  effective dates of April 1, 2010 through June 1, 2011.  (GF plans for effective dates of October 1, 2010 through March 1, 2011 only)

Spanish

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

Waiver of Coverage Form
When the employer contribution for the employee premium is less than 100%, employees may waive coverage as long as the total enrollment for the group does not drop below 75%. 

Deductible Credit Form
See Instructions for Completing Deductible Credit Forms.

PBC RX Mail Order

PBC RX Claim Form

PBC Medical/Dental Claim

LifeWise Health Plan of WA - Located in Clark County Only

2010-11 Employee  Application
For enrollees of groups covered by LifeWise Health Plan of WA with group effective dates of 04/01/2010 through 06/01/2011.

Spanish

Waiver of Coverage Form

When the employer contribution for the employee premium is less than 100%, employees may waive coverage as long as the total enrollment for the group does not drop below 75%. 

Deductible Credit Form
See Instructions for Completing Deductible Credit Forms.

LWHPW RX Mail Order

LWHPW RX Claim Form

LWHPW Medical/Dental Claim Form
These forms are provided for members with coverage through LifeWise Health Plan of WA only (groups in Clark County WA ONLY).

Waiver of Coverage Form

When the employer contribution for the employee premium is less than 100%, employees may waive coverage as long as the total enrollment for the group does not drop below 75%.  See Quote Assumptions

Life and Disability Forms

Death Claim Form

Accelerated Death Form

Dismemberment Claim Form

Life Insurance Conversion Form
When no longer eligible for WAHIT group Life Insurance, you may convert all or part of your benefit amount to an individual life policy without evidence of insurability.

Waiver of Premium Form
LifeWise Assurance Company will waive your life insurance premiums on the employer paid coverage if you become disabled prior to your 60th birthday while you are insured under the plan, and after you have been continuously disabled for 6 months subject to due proof.

Domestic Partnership

Affidavit of Domestic Partnership
Employees that wish to add their domestic partners for insurance coverage whose partnership is not registered in the domestic partner registry of any state, should complete the appropriate form which should be retained by the employer for his/her records.  The employee should also submit an employee application indicating the addition to BSI.

Statement of Termination of Domestic Partnership
Employees that wish to delete their domestic partners for insurance coverage, should complete the appropriate form which should be retained by the employer for his/her records.  The employee should also submit an employee application indicating the deletion to BSI.

Administrative Forms

COBRA Administration Agreement
Complete and return this form to Benefit Solutions, Inc. (BSI) to have BSI administer COBRA for your WAHIT coverage.  COBRA Administration will begin when BSI notifies the Employer that the service is in place.

Employer Name or Tax ID Change Form
Use this form to communicate a change to Employer name, DBA, Tax ID or Industry

Review Forms

Request for Review Form (not for medical claims)
WAHIT has established procedures for employers to request a review of any decision involving eligibility, enrollment and disenrollment, probationary periods, late payment, reinstatement and similar issues involving day to day  administration of WAHIT.  Complete the form and submit to WAHIT Review Committee c/o BSI. 
See Group Administrative Guide for more information.