Form Ciefdpw-3 1/16 - Awc Combined Insurance Enrollment Form Page 4
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4Employer
Employees: Employer will complete this section.
Send completed form to: 1076 Franklin Street SE, Olympia, WA 98501-1346
Employer name
Date of hire
Effective date of change
Employee’s occupation Weekly hours Monthly base earnings Dept. name
Online billing dept. number
Type of enrollee: ❏ Active
❏ LEOFF I Active
Employer – Please note that failure to fully complete this form may result in this form being returned to you and will
delay the processing of the form. Please proof this form carefully.
Employee plan enrollment
(Please check all that apply.)
Medical
Dental
Vision
Life
1800 Ninth Ave
3333 Quality Drive
1100 SW 6th Ave
Seattle, WA 98101
9706 Fourth Ave NE
Rancho Cordova, CA 95670
Portland, OR 97204
❏ Regence BlueShield
Vision Service Plan
Seattle, WA 98115
Standard Insurance Company
❏ AWC HealthFirst
®
Delta Dental of
(071038Z2)
❏ Basic Life $ ____________
❏ AWC HealthFirst
250
®
Washington
❏ No deductible (0001)
❏ Accidental Death &
❏ AWC HealthFirst
500
®
Basic (0177)
❏ $10 deductible (0002)
Dismemberment
❏ High Deductible Health Plan
❏ Plan A
❏ $25 deductible (0005)
❏ Plan A – LEOFF I only
❏ Dependent Life
❏ Plan B
❏ Low option plan
❏ Plan option 1
❏ Plan C
❏ Second pair rider
❏ Plan option 2
❏ Plan D
❏ Plan E
❏ Employee Additional Life
❏ Plan F
$ ____________________
528 E Spokane Falls Blvd, Suite 301
❏ Plan G
Spokane, WA 99202
Note: EOI form required if
Employee
❏ Asuris Northwest Health
over $80,000.
Assistance
❏ AWC HealthFirst
Orthodontia
®
❏ Spouse Additional Life
❏ AWC HealthFirst
250
❏ Option I
®
$ ____________________
Program
❏ AWC HealthFirst
500
❏ Option II
®
Note: Cannot exceed 50% of
❏ High Deductible Health Plan
❏ Option III
employee additional life. EOI
required, if over $20,000.
❏ Plan A – LEOFF I only
❏ Option IV
❏ Option V
NBC Tower
455 N. Cityfront Plaza Drive
Long-term
Chicago, IL 60611-5322
ComPysch
Disability
❏ 1-3 sessions -
Included
when enrolled on any
AWC Trust plan
320 Westlake Ave N, Suite 100
6950 NE Campus Way
❏ 1-5 Buy-up
Seattle, WA 98109-5233
Hillsboro, OR 97124
❏ 1-8 Buy-up
❏ Group Health Cooperative
Willamette Dental of
1100 SW 6th Ave
----------------------------
❏ $I0 copay
Portland, OR 97204
Washington, Inc.
No Trust benefits
❏ $20 copay, $200
Standard Insurance Company
❏ $I0 copay
❏ 1-3 sessions
deductible plan
❏ 90-day: 60% benefit
❏ $I5 copay
❏ 1-5 sessions
❏ High Deductible Health Plan
❏ 90-day: 67% benefit
❏ 1-8 sessions
❏ No copay – LEOFF I only
❏ 180-day: 60% benefit
❏ 180-day: 67% benefit
❏ Group Health Options, Inc.
❏ Access PPO
❏ Decline medical coverage
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