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Below you will find WCIF plan forms separated by carrier. Scroll down to browse, or go directly to the section you're searching for with the quick link tool below.

General Forms
Benefit Enrollment & Change Form:
• 2012 Employee Applications:
- Group Benefit Enrollment & Change Form \| All Lines - PDF Form > - Word Document (download) >
- Group Benefit Enrollment & Change Form \| Non-Medical - PDF Form > - Word Document (download) >
- Demographic Change Form - PDF Form > - Word Document (download) >

HIPAA Forms
• Waiver of Medical Coverage Form - Notice of Special Enrollment Rights and Consequences of Declining Coverage
• HIPAA Authorization for Release of Personal Health Information (PHI)

Domestic Partnership Forms:
• Affidavit of Domestic Partnership
• Declaration of Termination of Domestic Partnership

COBRA Forms
• COBRA Notice to Employer of a Qualifying Event

Medical Plan Forms
Premera Blue Cross PPO Plans*	Group Health Options HMO Plans
Plans \| Contact \| Rates	Plans \| Contact \| Rates
• Medical Claim Form (.doc)	• Medical & Prescription Claim Form
• Coordination of Benefits Questionnaire	• Coordination of Benefits Questionnaire
• Disabled Dependent Certification	• Physician Selection / Change Form

Prescription Forms	Prescription Forms
Prescription benefit information >	Prescription benefit information >
• Prescription Claim Form	• Medical & Prescription Claim Form
• Prescription Mail Order Enrollment Form	• Prescription Mail Order New Rx Form
- Health, Allergy & Medication Questionnaire * LifeWise of Washington for members whose employer is located in Clark County	• Prescription Mail Order Refill Form
	• Prescription Mail Order Transfer Form

Dental Plan Forms
Washington Dental Service (WDS)
Plans \| Contact \| Rates
• Dental Claim Form
• Coordination of Benefits Questionnaire (.doc)

Vision Plan Forms
Vision Service Plan (VSP)
Plans \| Contact \| Rates
• Vision Claim Form / Out-of-Network Reimbursement

Life & AD&D Plan Forms
The Standard Insurance Company \| Life & AD&D
Plans \| Contact \| Rates
• Life Claim Form Packet
• Beneficiary Desgination Form (Minor Beneficiaries' Payout Options)
• Accelerated Benefit Claim Form for Employees
• Accelerated Benefit Claim Form for Spouses / Dependents
• Waiver of Premium Claim Form

Basic Life Forms
• Group Life Portability Application
• Request for Conversion Materials

Voluntary Term Life (VTL) Forms
• VTL Enrollment & Change Form
• VTL Portability Application
• Medical History Statement

Voluntary Accidental Death & Dismemberment (VAD&D) Forms
• VAD&D Claim Form
• VAD&D Enrollment & Change Form

Disability Plan Forms
The Standard Insurance Company \| Disability
Plans \| Contact \| Rates
• Medical History Statement

Long Term Disability (LTD) Forms
• LTD Claim Form
• LTD Conversion Form

Voluntary Short Term Disability (VSTD) Forms
• VSTD Claim Form
• VSTD Enrollment & Change Form

Flexible Spending Account Forms
Benefit Solutions, Inc. (BSI)
Plans \| Contact \| Rates
• Enrollment Form
• Claim Form
List of qualifying FSA expenses >

Health Savings Account Forms
Benefit Solutions, Inc. (BSI)
Plans \| Contact \| Rates
• Claim Form

Retiree Plan Forms
see Retiree Plans page >