WAHIT Employer Forms Library

The following forms are provided for your assistance in administering your clients' benefits with WAHIT.

Plan Description	Form
Premera Blue Cross Forms - NOT Located in Clark County
2007-08 PBC Master Application For all new and renewing employers who are NOT located in Clark County WA, and have their medical coverage through Premera Blue Cross. The master application certifies the group's vital information of coverage, agreement with the terms of the trust, and appoints the broker or agent of record.	Click Here
2007-08 Employee Application For enrollees of groups covered by Premera Blue Cross with effective dates on or after 10/012007.	Click Here
2006-07 Employee Application For enrollees of groups covered by Premera Blue Cross with effective dates of 10/01/2006 through 09/01/2007.	Click Here
Request for Certification of Overage Dependent For requesting certification of an overage (25+ years) dependent. See your medical benefit booklet for more information.	Click Here
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	Click Here
Deductible Credit Form See Instructions for Completing Deductible Credit Forms.	Click Here
PBC RX Mail Order	Click Here
PBC RX Claim Form	Click Here
PBC Medical/Dental Claim	Click Here
LifeWise Health Plan of WA - Located in Clark County Only
2007-08 LWHPW Master Application For new and renewing employers located in Clark County WA, and who have their medical coverage through LifeWise Health Plan of WA. The master application certifies the group's vital information of coverage, agreement with the terms of the trust, and appoints the broker or agent of record.	Click Here
2007-08 LWHPW Employee Application For enrollees of groups covered by LifeWise Health Plan of WA with effective dates on or after October 1, 2007.	Click Here
2006-07 LWHPW Employee Application For enrollees of groups covered by LifeWise Health Plan of WA with effective dates of 10/01/2006 through 09/01/2007.	Click Here
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	Click Here
Deductible Credit Form See Instructions for Completing Deductible Credit Forms.	Click Here
LWHPW RX Mail Order	Click Here
LWHPW RX Claim Form	Click Here
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).	Click Here
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	Click Here
Life and Disability Forms
Death Claim Form See Key Contacts.	Click Here
STD Claim Form See Key Contacts.	Click Here
Accelerated Death Form See Key Contacts.	Click Here
Dismemberment Claim Form See Key Contacts.	Click Here
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.	Click Here
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.	Click Here
Affidavit of Domestic Partnership Employees that wish to add 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 addition to BSI.	Click Here
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.	Click Here
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.	Click Here
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.	Click Here