Enrollment Information

Group Enrollment Forms

One Platform Login 2023 Enrollment Checklist
One Platform Resources Group Size Attestation
Renewal Re-Rate Process Late Enrollment Acknowledgement Form
Double and Triple Choice Options
Premera Products Only Enrollment Census Template (One Platform)

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

Amy Easely – Western WA

Rachel Miller – Eastern WA
Deductible Credit Process

 

Member and Other Enrollment Forms

Member enrollment and change application Request for certification of disabled dependent
Member enrollment and change application (Spanish version) Waiver of coverage
Affidavit of domestic partnership group plans Transition of care form
Deductible credit form Administrators Quick Reference Guide
Enrollment Exception Request

 

HSA Documents

2023 Personal Funding Account Setup Form Funding Account ACH Authorization Form
PFA (Personal Funding Account enrollment application) Funding Account Employer Admin Guide