Forms

Employer Proposal:

Employer Large Group Proposal Form (PDF)

Employee Enrollment Form:

Self-Funded Health History Questionnaire:

Self-Funded Health History Questionnaire (PDF)

Employee Change of Status Form

(Use this form if you need to change your name, you need to add or delete dependents, or you need to change your beneficiary.)

Coordination of Benefits Form:

(Use this form to let us know if you or any of your dependents are currently covered under any other health benefit plan in addition to your coverage with WMI TPA.)

Accident Claims:

(Use this form if we have requested accident information from you regarding a claim.)

HIPAA Authorization for Release of Information:

(use this form if you need to give us authorization to request or release your protected health information)

COBRA Forms:

COBRA Initial Notice (PDF)
COBRA Notice of Qualifying Event (PDF)