New Group Enrollment Checklist
For Washington Groups of up to 50 Employees
Completed enrollment materials must be received at Premera by the following dates prior to the desired effective date to ensure eligibility is active on the effective date; incomplete materials may cause delays enrolling a group:
· 5 th of the month for HSA plans
· 10 th of the month for all other plans
· Materials received after the 5 th of the month for H SA plans must include a signed Late Enrollment Acknowledgement form
· Materials received between the 11-20 th for all other plans must include a signed Late Enrollment Acknowledgement form
· Enrollment materials cannot be received after the 20 th of the month for the following month’s effective date
1. COMPLETE THE NECESSARY ENROLLMENT FORMS . All forms are available at p remera.com.
Group Master Application up to 50
Group Master Application Benefit Selections up to 50
Member Enrollment and Change Application for every eligible employee
(members must include date of hire and prior coverage)
Enrollment Spreadsheet (for groups with 10+ employees)
(member enrollment and change applications not required to be submitted)
Late Enrollment Acknowledgement Form (if applicable)
Group of One Attestation Form and W-2 (if applicable)
ADDITION AL FORMS REQUIRED FOR HSA P LANS
Funding Account Setup - For Metallic Groups
Electronic Funding Authorization
Personal Funding Accounts Enrollment and Change Application
2. SMALL GROUP QUOTE AND QUOTE CENSUS
3. SEND ALL COMPLETED ENROLLMENT MATERIALS TO YOUR GENERAL AGENCY PARTNER :
o Connexion Insurance Solutions
o ProPoint Business Solutions
o S4 Benefits
Questions? Please contact your General Agency Partner.
012301 (12-01-2017)
An Independent Licensee of the Blue Cross Blue Shield Association