|
Plan Administrator - MBA - Forms
The following forms are provided for your convenience.
They are saved in pdf format (requires the free Adobe Acrobat Reader) and can be printed from your computer. If you have trouble printing, or if you would like a form mailed to your company, you may contact a Benefits Administrator at:
EPK & Associates Staff
15375 SE 30th Place, Suite 380
Bellevue, WA 98007
phone (425) 641-7762 or 1-800-545-7011 extension 5
fax 425-641-8114
e-mail admin@epkbenefits.com
 Employer Participation Agreement
Employers use this form for initial sign-up to establish the benefits to be offered, define eligibility for coverage, and provide billing information to the Trust Administrator. Both the Trust Administrators and the Carriers use this contract throughout the plan year for benefit and eligibility determination.
Employee/Subscriber Application (please note: this form is 2 pages)
This form is filled out by each eligible employee or owner who will be covered by a Trust plan. This form is used for initial enrollment, for adding new employees, to add a dependent, to change a beneficiary, or to change a medical plan.
Additional Life Insurance Form
Employees use this form to apply for additional life insurance coverage through the Trust.
Change Transmittal Form
Employers use this form to cancel employee or dependent coverage, or to update certain insurance information (i.e. address change).
COBRA Continuation Coverage Election Form (please note: this form is 2 pages)
Former employees of your company use this form to elect to continue coverage on a self-pay basis through the Trust.
Employee Waiver of Insurance Form
Employees use this form when an otherwise eligible employee wants to decline or waive enrollment in the Trust program due to other health insurance coverage.
Domestic Partner Packet
|
