2015 Enrollment Checklist

Enrollment Checklist for 2015 Premera Small Group Plans
Premera Blue Cross Washington Groups of up to 50 Employees
All completed enrollment material must be in our office by the 1st of the month for HRA and HSA products or
5th of the month for all other products prior to the desired effective date to ensure eligibility is active on
the effective date. Incomplete materials may cause delays enrolling a group and its members. Materials
received after the above deadlines must include a signed Late Enrollment Acknowledgement form. See next
page for enrollment timelines.
Complete the necessary enrollment forms shown here. Most forms are found on our Connexion Insurance
website or you can click on the hyperlinks (underlined words) below.
 Group Master Application 2015 (complete and send to Connexion)
 Copy of binder check for first month’s premium (see address at the bottom for mailing live check)
 Late Enrollment Acknowledgement Form (if applicable – depends on date of submission)
 Group Master Application Benefit Selection Worksheet
 Copy of sold rate exhibit from Connexion’s Group Quote tool. Circle the plan and premium selected by group
 Copy of census page from Connexion’s Group Quote tool.

Member Enrollment and Change Application (Spanish version) Use for every employee enrolling on the
plan for groups under 10. Member must include date of hire, DOB, SSN, job title & signature. Keep Waiver forms
for your files, except send in for groups of 1 or 2 subscribers)

Enrollment xls for 10+ only (if you complete this, you don’t have to send the above items, just keep for your files)
Forms or
Spreadsheet
for 10+
 Tax documentation (for groups of 1 or 2 subscribers only)
HSA plans: the following documents are required:
 Electronic Funding Authorization
 Funding Account Set-up for Group *Annual payroll schedule required
 Personal Funding Account Enrollment and Change Application all covered employees (even if not contributing)
Not required: HSA Administrative Service Agreement Sample (provide to employer)
UMB Bank Terms and Conditions (provide to employees)
HRA plans: the following documents are required:
 Electronic Funding Authorization
 Funding Account Set-up for Group
 Personal Funding Account Enrollment and Change Application for each covered employee
 Business Associate Agreement (ERISA or Non-ERISA)
Not required: HRA Administrative Service Agreement Sample (provide to employer)
UMB Bank Terms and Conditions (provide to employees)
 Send forms and first month’s premium payable to Premera Blue Cross in the amount of plan(s) selected
Submit application materials
and copy of check online or
by email to pbcwasmallgroup
@connexioninsurance.com
Send live checks to:
Connexion Insurance
Solutions, PBC WA Small
Group, MS 320
Call Connexion at (888) 742-1475 if you have questions.
Enrollment Checklist 10-2015
Mail to MS 320:
PO Box 34315
Seattle, WA 98124-1315
Overnight:
6707 220th St. SW, MS 320
Mountlake Terrace, WA 98043
Premera Blue Cross Small Group
Enrollment Submission Timelines
Timeline Key
On time HSA/HRA Plan Enrollment materials to Connexion – 1st of the month.
On time PPO or PCP Plan Enrollment materials to Connexion – 5th of the month. To meet Connexion’s
deadline, any application received after the 5th requires a Late Enrollment Acknowledgment form.
Connexion must have all completed application materials by the date in Red.
Late Binder Checks to Connexion – Green – 1 business day after application materials deadline.
Final scrubbed enrollment and check from Connexion to Premera – 20th of the month unless on the weekend.
~ Mar. 2014 ~
~ Dec. 2014 ~
Sun Mon Tue Wed Thu
4
Fri
5
Sat
1
2
3
6
7 8
9
10 11 12 13
Sun Mon Tue Wed Thu Fri Sat
1 2
3
4
5
6
7
8 9
10 11 12 13 14
14 15 16 17 18 19 20
15 16 17 18 19 20 21
21 22 23 24 25 26 27
22 23 24 25 26 27 28
28 29 30 31
For January 2015
effective date
~ Jan. 2015 ~
Sun Mon Tue Wed Thu Fri Sat
For Feb. 2015
effective date
4 5
6
7
1
2
3
8
9
10
11 12 13 14 15 16 17
18 19 20 21 22 23 24
25 26 27 28 29 30 31
~ Feb. 2014 ~
Sun Mon Tue Wed Thu Fri Sat
1 2
3
4
5
6
7
8 9
10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
For March 2015
effective date
Enrollment Checklist 10-2015
29 30 31
For April 2015
effective date
Enrollment Checklist 10-2015

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