Producer Forms

• Application for the addition of family members to an individual/family or group conversion plan
• Tobacco certification form
• Non-smoker certification form
• Underwriting plan change matrix
• Claim form
• Individual producer of record change form

Proposals

• Request for rates
• Census template

Pre-Renewal

• Group size certification

New groups

Completed enrollment materials must be received at Premera for new groups by the 20th of the month to ensure eligibility by the plan start date.

• 2025 Small group master application
• 2025 Small group benefit selection worksheet
• 2024 Small group master application
• 2024 Small group benefit selection worksheet
• Member enrollment and change application
• Enrollment spreadsheet (for groups with 10 or more enrolled employees)
• Other coverage questionnaire

Send completed enrollment materials to AKPBCSmallGrpSS@PREMERA.com.

Renewing groups (2+ employees enrolled)

No action is necessary unless plan or group information changes are requested. Send change requests to AKPBCSmallGrpSS@premera.com and your designated account team no later than the 10^th of the month prior to the group’s renewal date by completing the group verification report and/or benefit selection worksheet.

Proposals

• Request for rates form (51-99)
• Census template (51-99)

Groups with 100 or more employees enrolled, please contact your Premera sales representative.

Pre-renewal

• Group size certification

New groups

Completed enrollment materials must be received at Premera well in advance of the first of the month to ensure eligibility and receipt of ID cards by the plan start date.

Required documents

• Fully insured group master application
• Self-funded group master application
• Circled, signed and dated rate exhibits to acknowledge your group's plan choice(s). For self-funded groups, this includes the admin and stop loss exhibits.
• Enrollment spreadsheet
• Member enrollment and change application
• Other coverage questionnaire

Return completed enrollment materials to Senior Sales Manager Bradley.Olson@premera.com and Implementation Account Specialist Kristin.Lara@premera.com.

Note: Additional forms will be provided for self-funded and Optiflex funding arrangements.

Renewing groups

Completed renewal documents and written confirmation must be received at Premera well in advance of the first of the month to ensure eligibility and receipt of ID cards by the group's renewal date.

Required documents:

• Group verification report (provided by Premera with group's renewal proposal)
• Circled, signed and dated rate exhibit(s) to acknowledge group’s plan choice(s). For self-funded groups, this includes the admin and stop loss exhibits.

Return completed renewal documents to your designated Account Manager and Implementation Account Specialist.

Note: Additional forms will be provided for any groups moving to self-funded or Optiflex funding arrangements.

Claim form

HSA, FSA, and HRA forms for new/renewing groups

• Personal funding account enrollment & change application
• Personal funding account setup form - small groups
• Personal funding account setup form - large groups
• Funding Account ACH Authorization
• HSA Account Closure form
• HSA Designation of Beneficiary form
• HSA Trustee to Trustee Transfer form
• Funding Account Employer Admin Guide - small groups - up to 50
• Funding Account Employer Admin Guide - large groups

• Express Scripts home delivery mail-order form - Order prescription drugs through the mail from Express Scripts. On behalf of Premera, Express Scripts is an independent company providing pharmacy benefits services.
• Health, allergy & medication questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
• Prescription drug reimbursement form - Apply for reimbursement of your prescription costs.

• Summary Health Info Authorization for Self-Funded PBCAK
• Summary Health Info Authorization for Insured Groups PBCAK
• Authorization for release of psychotherapy notes
• Disclosure accounting request
• Information Release Form - Give someone permission to obtain and discuss your personal and health information, including sensitive information such as substance abuse, reproductive health, and mental health. You can also authorize members on your plan to see your sensitive information on Premera.com or ConnectYourCare (medical funding account).
• Non-disclosure request
• Request for amendment of record
• Request for inspection of records

• Affidavit of domestic partnership
• AFT Authorization form for individual major medical
• Producer of record change form
• Waiver of coverage
• Request for certification of disabled dependent
• Deductible credit form
• Claim form