Forms

Montana (WPMA and MRA) Employer Application (PDF)
Use this form if you are an Montana employer that is applying for group coverage.

Washington WPMA Employer Application (PDF)
Use this form if you are a Washington WPMA Employer that is applying for group coverage.

All Other States WPMA Employer Application (PDF)
Use this form if you are an employer in a state other than Montana or Washington that is applying for group coverage.

Group Benefit Eligibility Criteria (PDF)
Annual Employer Audit (PDF)
All employers must complete these two forms.

Idaho
You must complete these two forms.
Employee Application (PDF)
Supplemental Information (PDF)
Enrollment form (PDF)

Montana
You must complete these two forms.
Employee Application (PDF)
Enrollment form (PDF)

Washington
You must complete these two forms.
Employee Application (PDF)
Enrollment Form (PDF)

Nevada
You must complete these two forms.
Employee Application (PDF)
Enrollment form (PDF)

Arizona
You must complete these two forms.
Uniform Questionaire (PDF)
Uniform Questionaire Appendix (PDF)

New Mexico
You must complete these two forms.
Employee Application (PDF)
Enrollment Form (PDF)

All other states
You must complete these two forms.
Employee Application (PDF)
Enrollment Form (PDF)

Employee Enrollment Forms (for already enrolled employer groups):

Idaho
Use this form if you are a new employee of an already enrolled employer group.
Enrollment form (PDF)

Montana
You must complete both of these forms if you are a new employee of an already enrolled employer group.
Enrollment form 1 (PDF)
Enrollment form 2 (PDF)

Washington
Use this form if you are a new employee of an already enrolled employer group.
Enrollment form (PDF)

All other states
Use this form if you are a new employee of an already enrolled employer group.
Enrollment form (PDF)

Employee Change of Status Form
Use this form if you need to change your name, you need to add or delete dependents, or you need to change
your beneficiary.
Change of Status form (PDF)

Prior Insurance:
Use this form to let us know if you or any of your dependents had health insurance coverage prior to your enrollment with WMI.
Prior Insurance Information (PDF)

Other Insurance:
Use this form to let us know if you or any of your dependents are currently covered under any other health insurance policy in addition to your coverage with WMI.
Coordination of Benefits Information (PDF)

Accident Claims:
Use this form if we have requested accident information from you regarding a claim.
Accidental Injury Information Request (PDF)

HIPAA Forms:
Use this form if you need to give us authorization to request or release your protected health information.
HIPAA Authorization for Release of Information (PDF)

COBRA Forms:
COBRA Initial Notice (PDF)
COBRA Notice of Qualifying Event (PDF)

Completed forms can be mailed to WMI at:
P.O. Box 572450;
Murray, UT 84157-2450

Or faxed to:
Enrollment Forms: 801.263.1247
Claims Forms: 801.263.1189