Forms

Employer Proposal:
Employer Large Group Proposal Form (PDF)

Employee Enrollment Form:
Employee 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 benefit coverage prior to your enrollment with WMI TPA.)
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 benefit plan in addition to your coverage with WMI TPA.)
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