This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.
All relevant documentation must be submitted to WHA by the 5th of the month:
- Employer Group Application (to be completed by employer).
Enrollment/Change Form for each enrollee (with HSA Authorization Form, if applicable)
- Declination of Coverage forms for each eligible employee who decline group health coverage for themselves and/or their dependents.
A payment for the first month's premium on company check stock (electronic payment options are available once the group has been installed).
One of the following options:
- For Employers: a copy of the most recent Quarterly Contribution Return and Report of Wages (Continuation) (DE-9C)
- For LLCs and Partnerships: a copy of most recent Schedule K listing all members or partners
Applicable group supporting documentation must accompany group application:
|After approval, prior carrier termination letter must be submitted by the employer or broker.|
For other useful or older documents, please refer to the Forms database.
Important Reminder: To help your client comply with ACA requirements, provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at the Enrollment Meeting, via email or by posting on an internal company website. For the most recent information regarding Western Health's SBC's, please go to the SBC Page or contact your Word & Brown representative.