Enrollment Information

Group Enrollment Forms

2021 Enrollment Checklist One Platform Login
2021 PBC Group Master Application One Platform Resources
2021 Benefit Selections Renewal Re-Rate Process
2021 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
Electronic funding authorization (HSA) Member Enrollment and Change Form
Group Size Attestation


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

2021 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