Enrollment Information

Premera Group Enrollment Forms

• One Platform Login
  • One Platform Resources
• Renewal Re-Rate Process
• 2026 Medical Benefit Selection Worksheet
• 2026 Dental Benefit Selection Worksheet
• Group Deductible Credit Process Questions, email GroupMedical@ConnexionInsurance.com
• Enrollment Census Template (Only for Premera Products – One Platform)
• 2026 Enrollment Checklist
• 2026 Employer Group Application
  • Sample Small Group Application
• Group Size Attestation
  • Sample Group Attestation
• For Small Group Add-On Ancillary Product Questions or Help:
  • Amy Easley – Western Washington 
  • Emelie Hoffman – Eastern Washington  

 

Premera Member Info and Other Enrollment Forms

• 2026 Member Enrollment and Change Application (English)
• 2026 Member Enrollment and Change Application (Spanish)
• Request for Certification of Disabled Dependent
• Waiver of Coverage
• Affidavit of Domestic Partnership Form
• Transition of Care Form
• Individual Deductible Credit Form
• Administrators Quick Reference Guide
• Enrollment Exception Request

 

Premera HMO Forms

• HMO Core Plus Flyer

The benefits of Premera Blue Cross HMO make it an easy choice as a stand-alone plan or alongside our larger plans. It offers:

• Affordability
• Care guided by primary care providers (PCPs)
• Seamless customer service
• Whole-person approach to care
• A streamlined digital experience

Premera Blue Cross HMO is available to small groups, fully insured groups of 51 or more employees, and self-funded groups as a fully insured offering.

• 2026 Employer Group Application – HMO
• 2026 Medical Benefit Selection Worksheet – HMO
• 2026 Member Enrollment and Change Application – HMO

 

Contact Your Sales Exec for more information:

Amy Easley – Western Washington

Emelie Hoffman – Eastern Washington

 

Premera HSA Documents

Personal Funding Account Setup Form	Funding Account ACH Authorization Form
Personal Funding Account Enrollment Application	Funding Account Employer Admin Guide

 

Premera Renewal Information

• Renewal Quick Start Guide

For all Premera Producer Resources and Forms: https://www.premera.com/wa/producer/resources/forms/

Note: Premera Blue Cross is an independent licensee of Blue Cross and Blue Shield Association.