Enrollment Information

Group Enrollment Forms

2022 Enrollment Checklist	One Platform Login
2022 PBC Group Master Application	One Platform Resources
2022 Benefit Selections	Renewal Re-Rate Process
2022 Deadline Calendar	Double and Triple Choice Options
Late Enrollment Acknowledgement Form	Ordering Member ID Cards
Premera Products Only Enrollment Census Template (One Platform)	Deductible Credit Process
Medical and Ancillary Enrollment Census Template (One Platform)	Deductible Credit Form
Late Enrollment Acknowledgement Form	Group Size Attestation
Electronic funding authorization (HSA)	2022 Member Enrollment and Change Form
	2021 Member Enrollment and Change Form

 

Member and Other Enrollment Forms

Member enrollment and change application	Other coverage questionnaire enrollment
Member enrollment and change application (Spanish version)	Personal funding accounts enrollment and change application
Affidavit of domestic partnership group plans	Request for certification of disabled dependent
Deductible credit form	Waiver of coverage
Enrollment spreadsheet (in lieu of member enrollment applications)	Transition of care form
HIPAA pre-existing change notice and instructions	Quick reference guide for plan administrators
HIPAA pre-existing change notice and instructions (Spanish version)	Enrollment Exception Request

 

Member, UMB Bank Forms

2022 Personal Funding Account Setup Form	UMB HSA funds transfer
UMB HSA name change request form	HSA expense manual claim form
UMB HSA account closure/withdrawal request	UMB HSA beneficiary designation form