Premera Group Enrollment Forms
| One Platform Login | 2025 Enrollment Checklist |
| One Platform Resources | 2025 Small Group Master Application |
| Renewal Re-Rate Process | Group Size Attestation |
| For Help with the Group Deductible Credit Process: GroupMedical@ConnexionInsurance.com | |
| 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 |
Premera Member Info and Other Enrollment Forms
| 2025 Member Enrollment and Change Application (English) | Request for Certification of Disabled Dependent |
| 2025 Member Enrollment and Change Application (Spanish) | Waiver of Coverage |
| Affidavit of Domestic Partnership Form | Transition of Care Form |
| Individual Deductible Credit Form | Administrators Quick Reference Guide |
| Enrollment Exception Request | 2025 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:
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.
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 |
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.