Forms

These forms are available to print out only (requires Adobe Acrobat reader).

Enrollment forms

• AWC Combined Insurance Enrollment Form
• Marriage/Domestic Partnership Affidavit – Documentation
• Marriage/Domestic Partnership Affidavit – No documentation
• Termination of Marriage/Domestic Partnership
• AWC Change of Address Form

Employer Master Participation Agreement form

• AWC Employer Master Participation Agreement

Non-city entity forms

• Non City Entity Application Form
• Employer Master Participation Agreement - Non-City Entity

Online billing forms

• Online Billing Authorization Form

Long-term disability forms

• Long Term Disability Participation Agreement
• Long Term Disability Claim Form

Life insurance forms

• Life Insurance Participation Agreement
• Evidence of Insurability Form
• Life Insurance Benefit Application Form
• Accelerated Death Benefit Form
• Waiver of Premium Form
• Group Conversion Packet

Regence and Asuris forms

• Incident Report
• PPS Prescription Mail Order Form
• Personal Health Information Authorization Form (HIPAA PHI Release Form)

COBRA forms

• Notice to Administrator Form (Employee)
• Notice to Administrator Form (Spouse/Dependent)
• COBRA Enrollment Form

USERRA forms

• Notice to Administrator Form
• USERRA Enrollment Form
• Initial Notification of Rights: Letter to New Employees

Retiree enrollment forms

• Medical Enrollment Form
• Dental Enrollment Form

Click here to download Abode Acrobat reader (free).

 

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