WAHIT Employer Forms Library


The following forms are provided for your assistance in administering your benefits with WAHIT.

Plan Description

Form

Premera Blue Cross WAHIT Forms Medical and Dental Forms

2017-2018 Employee Application
For enrollees of groups covered by Premera Blue Cross with group effective dates of July 1, 2017 through June 30, 2018

Click Here

2016-2017 Employee Application  
For enrollees of groups covered by Premera Blue Cross with group effective dates of July 1, 2016 through June 30, 2017

Click Here

Request for Certification of Overage Dependent
For requesting certification of an overage (25+ years) dependent. See your medical benefit booklet for more information.

Click Here

Waiver of Coverage Form

Click Here

Deductible Credit Form

Click Here

PBC RX Mail Order

Click Here

PBC RX Reimbursement Form

Click Here

PBC Medical/Dental Claim

Click Here

USAble Life Insurance Company Life & Disability Forms

USAble Supplemental Life Enrollment Form

Click Here

USAble Evidence of Insurability Form

Click Here

USAble Appeal Form

Click Here

USAble Beneficiary Change Form

Click Here

USAble Authorization for Release of Medical Records

Click Here

USAble Statement of Claim Group Accident Insurance

Click Here

USAble Application for Extended Insurance Benefits

Click Here

USAble Extended Life Insurance (Waiver of Premium) Update Form

Click Here

USAble Proof of Death Form

Click Here

USAble Accelerated Death Benefits Statement of Claim Form

Click Here

USAble Application for Portability of Group Term Life Form

Click Here

USAble Life Insurance Release of Absolute Assignment Form

Click Here

USAble Request for Conversion Form

Click Here

Domestic Partnership

Affidavit of Domestic Partnership

Click Here

Administrative Forms

USAble COBRA Administration Agreement

Click Here

USAble Employer Name or Tax ID Change Form

Click Here