MBA Trust PDF 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. They can be sent to us by scan/email, fax, or mail.
Employee/Subscriber Application: select from the options below (please note: this form is 2 pages)
The following forms can be filled out by each eligible employee, group administrator, or owner. These forms are used for initial enrollment, adding new employees, adding a dependent, changing a beneficiary, changing a name, changing a medical plan during an open enrollment period, or changing the address:
- MBA Regence BlueShield or Kaiser Permanente
- MBA Asuris Northwest or Kaiser Permanente
- MBA Voluntary Dental and/or Vision
MBA Voluntary Life Insurance Form Employees use this form to apply for additional term life insurance coverage through the Trust.
MBA Change Transmittal Form is used by employers to cancel employee or dependent coverage, or to update certain insurance information (i.e. address change).
Employee Waiver of Insurance Form groups 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 for groups interested in offering non-state registered Employee Domestic Partner dependent coverage.
Forms can be sent to us via:
Scan & Email: firstname.lastname@example.org
15375 SE 30th Place, Suite 380
Bellevue, WA 98007