Enrollment Information

Group Enrollment Forms

One Platform Login 2024 Enrollment Checklist
One Platform Resources 2024 Small Group Master Application 
Renewal Re-Rate Process Group Size Attestation
Double and Triple Choice Options Late Enrollment Acknowledgment Form
Premera Products Only Enrollment Census Template (One Platform)

Note: For Ancillary Products Contact Your Sales Exec for Personal Assistance:

Amy Easley – Western Washington

Emelie Hoffman – Eastern Washington

 2024 Benefit Highlights
Deductible Credit Process

 

Member and Other Enrollment Forms

2024 Member Enrollment and Change Application

(English Version)

 Request for Certification of Disabled Dependent 
2024 Member Enrollment and Change Application

(Spanish Version)

 Waiver of Coverage
Affidavit of Domestic Partnership Form Transition of Care Form
Deductible Credit Form Administrators Quick Reference Guide
Enrollment Exception Request 2024 HMO Plan Benefit Guide

 

HSA Documents

2024 Personal Funding Account Setup Form Funding Account ACH Authorization Form
PFA (Personal Funding Account enrollment application) Funding Account Employer Admin Guide