Form Ciefdpw-3 1/14 - 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 ❏ LEOFF I Retiree
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.
Plans enrolled on
(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)
❏ High Deductible Health Plan
Dismemberment
❏ 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
❏ Asuris Northwest Health
over $80,000.
❏ AWC HealthFirst
Orthodontia
®
❏ Spouse Additional Life
❏ AWC HealthFirst
250
❏ Option I
®
$ ____________________
❏ AWC HealthFirst
500
❏ Option 11
®
Note: Cannot exceed 50% of
Employee
❏ High Deductible Health Plan
❏ Option 111
employee additional life. EOI
Assistance
required, if over $20,000.
❏ Plan A – LEOFF I only
❏ Option IV
❏ Option V
Program
Long-term
Disability
NBC Tower
455 N. Cityfront Plaza Drive
Chicago, IL 60611-5322
320 Westlake Ave N, Suite 100
6950 NE Campus Way
ComPysch
Seattle, WA 98109-5233
Hillsboro, OR 97124
❏ 1-3 sessions
❏ Group Health Cooperative
Willamette Dental of
1100 SW 6th Ave
❏ 1-5 sessions
❏ $I0 copay
Portland, OR 97204
Washington, Inc.
❏ 1-8 sessions
❏ $20 copay, $200
Standard Insurance Company
❏ $I0 copay
deductible plan
❏ 90-day: 60% benefit
❏ $I5 copay
❏ High Deductible Health Plan
❏ 90-day: 67% benefit
❏ No copay – LEOFF I only
❏ 180-day: 60% benefit
❏ 180-day: 67% benefit
❏ Group Health Options, Inc.
❏ $250 deductible plan
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