New Group Enrollment Checklist
For Premera Blue Cross Washington Groups of up to 50 Employees
All completed enrollment material must be in our office by the 1st of the month for HRA and HSA products or 5th of the month prior to the desired effective date to ensure eligibility is active on the effective date. Incomplete materials may cause delays enrolling a group. Materials received after the above deadlines must include a signed Late Enrollment Acknowledgement form.
1. Complete the necessary enrollment forms shown here. Most forms are found on premera.com.
___ Group Master Application 2014
___ Group Master Application Benefit Selection Worksheet
___ Member Enrollment and Change Application (Spanish version) or Waiver of Coverage for every eligible Employee (members must include date of hire and prior coverage)
___ Enrollment spreadsheet (for groups with 10+ employees)
___ Deductible Credit Form (include prior carrier’s Explanation of Benefits)
___ Late Enrollment Acknowledgement Form (if applicable – depends on date of submission)
2. Additional forms for HSA and HRA plans
___ Electronic Funding Authorization
___ Funding Account Set-up for Group
___ Personal Funding Account Enrollment and Change Application for each covered employee
UMB Bank Terms and Conditions (provide to employees – not required to set up group)
3. Additional form required for HRA plans
___ Business Associate Agreement (ERISA or Non-ERISA)
4. ___ Copy of quote and census pages
5. ___ Check for the first month’s premium payable to Premera Blue Cross.
Send completed enrollment material to:
Connexion Insurance Solutions
Attn: Cindy Brooks, PBC WA Small Group
PO Box 34315
Seattle, WA 98124-1315
Want to send electronically? Please call the Connexion PBC WA Small Group team at (888) 742-1475 to discuss secure options.
Enrollment Checklist 12-23-2013