S4 Benefits Logotype
  • Home
  • Quotes
  • Resources
    • Resources
    • Premera Plan Information
    • Premera Forms
    • Plan Features
    • Provider Networks
    • Adult Dental and Vision Plans
    • Medicare Part D Information
  • Contact
Section background
  • Home
  • Premera Forms

Premera Forms

Small Group Forms

  • 2023 New Group Enrollment Checklist
  • 2023 Master Application Benefit Selections
  • 2023 Small Group Master Application
  • 2022 Washington Small Group Quote Assumption
  • 2023 Dental Benefit Selection
  • Group Size Attestation
  • Personal Funding Account Setup - for metallic groups
  • Electronic Funding Authorization (HSA)
  • Late Enrollment Acknowledgment
  • Quick Reference Guide for Plan Administrators
  • Key Employee Verification
  • Kinwell Health

Member Enrollment and Other Forms

  • 2023 Member Enrollment And Change Application
  • Member Enrollment and Change Application (Spanish version)
  • 2023 Member Enrollment and Change Application (Spanish)
  • Affidavit of Domestic Partnership Group Plans
  • Deductible Credit Form
  • Enrollment Spreadsheet (in lieu of member enrollment applications)
  • Other Coverage Questionnaire Enrollment
  • Personal Funding Accounts Enrollment and Change Application
  • Request for Certification of Disabled Dependent
  • Waiver of Coverage
  • Transition of Care Form
CUSTOMER SERVICE AND SUPPORT Service@S4benefits.com Office: 833-589-2189 Logotype