Small Group Forms
- S4 Benefits Small Group Enrollment Checklist
- 2025 Small Group Master Application
- 2025 HMO Small Group Master Application
- 2025 Medical Benefit Selection Worksheet
- 2025 Dental Benefit Selection Worksheet
- 2025 Medical HMO Benefit Selection Worksheet
- 2025 WA Small Group Underwriting Assumptions
- 2025 WA HMO Small Group Underwriting Assumptions
- Group Size Attestation
- Personal Funding Account Setup - for metallic groups
- Electronic Funding Authorization (HSA)
- Key Employee Verification
- Kinwell Health
- Quick Reference Guide for Plan Administrators who pay through e-billing platform
- Quick Reference Guide for Plan Administrators who receive a paper invoice
- Late enrollment acknowledgement
Member Enrollment and Other Forms
- 2025 Member Enrollment and Change Application
- 2025 Member Enrollment and Change Application (Spanish)
- Affidavit of Domestic Partnership Group Plans
- Deductible Credit Form
- S4 Wired Quote Form 08212023
- Enrollment Census For Multiple Class And Muti Plan Offering
- Other Coverage Questionnaire Enrollment
- Personal Funding Accounts Enrollment and Change Application
- Request for certification of disabled dependent
- Waiver of Coverage
- Transition of Care Form