Acknowledgements & Disclosures
IMPORTANT NOTE: If you are not the person who will be signing this document, please do not fill out the signature field. Scroll to the bottom and click SUBMIT. Once you click SUBMIT, you will be emailed a copy of your filled out form to sign and complete. Please submit all signed forms to renewals@wcif.net.
Employer agrees to abide by the provisions of the Washington Counties Insurance Fund (WCIF) Trust Agreement and Bylaws.
Extent of Coverage
Employee benefits will end on the last day of the month in which the employee becomes ineligible (except as specified under federal and/or Washington state mandated extension rights). Employers may not continue an employee's coverage on any active plan after the employee is no longer eligible. The only exception to this rule is for employees who lose coverage due to a disability and need to continue life and disability plan coverage in order to apply for Waiver of Premium at a later date. Continuation of coverage through COBRA and retiree plans (for retirees under the age of 65) is available to employees who qualify; provided the employer maintains participation in a WCIF medical, dental, vision, EAP, and/or CDH plan(s).
Continuation of coverage is available in accordance with federal and Washington state law to members who become ineligible for group coverage. Employers have a legal responsibility for certain notification requirements. Please reference the WCIF eACE Manual (www.wcif.net) for notification procedures and forms for WCIF plans. Employers may also reference the US Department of Labor (www.dol.gov) and the US Internal Revenue Service (www.irs.gov) for further guidance. Advisory assistance on compliance with federal and state employment law regulations should be obtained from an employment attorney.
Medical Participation
Employers who offer WCIF medical coverage are required to cover a minimum of 75% of all eligible employees after excluding those waiving due to other qualifying coverage.
NOTE: For current groups who do not submit the Master Application by December 1, group benefits will default to their prior year elections, if available, or mapped to most comparable plan.
Waiver of Medical Insurance (for groups offering WCIF medical coverage)
Employer acknowledges that employees with other verifiable group medical coverage (i.e., another employer plan, Medicare, TriCare, VA (with ACA letter), Washington Healthplanfinder) are considered eligible participation exclusions, and do not count against the medical participation requirement. Employees with individual medical coverage outside Washington Healthplanfinder are not considered eligible participation exclusions and will count against a group's medical participation requirement.
Employer acknowledges that in order to allow an employee to waive WCIF medical coverage the employee must provide the employer with proof of other group medical insurance coverage.
Employer acknowledges that they may not offer cash incentives to employees who waive WCIF medical coverage.
Employers are required to offer the same coverage to their over age 65 employees (and over age 65 spouses/domestic partners) as they do to all other eligible employees. Employer coverage is primary to Medicare. Medicare beneficiaries are free to waive employer plan coverage, in which case they retain Medicare as their primary coverage. When Medicare is primary payer, employers cannot offer such employees (or their spouses) secondary coverage (or incentives) for items and services covered by Medicare.
PLEASE NOTE: If you are not the person who will be signing this document, please click SUBMIT now. You will be emailed a filled PDF form, which can then be emailed to the signer, or printed and signed. Please send final signed applications to renewals@wcif.net.
Signature
The below signed applicant agrees that if the requested insurance is acceptable to WCIF under its current rules and practices and is legally permissible, a policy will be issued in the policy language customarily used by WCIF and will be effective on the date determined by WCIF.
The below signed applicant acknowledges it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTE: You can also sign this document by clicking Submit
Carrier Information
Premera Blue Cross
7001 220th St SW
Mountlake Terrace, WA 98043
Plan number unique to employer.
Contact WCIF at (800) 344-8570 to obtain.
Premera Blue Cross is an independent licensee of the Blue Cross Blue Shield Association.
Kaiser Foundation Health Plan of WA Options, Inc.
1300 SW 27th St
Renton, WA 98057
Plan number unique to employer.
Contact WCIF at (800) 344-8570 to obtain.
Kaiser Foundation Health Plan of WA
1300 SW 27th St
Renton, WA 98057
Plan number unique to employer.
Contact WCIF at (800) 344-8570 to obtain.
Delta Dental of Washington
400 Fairview Avenue N, Suite 800
Seattle, WA 98109
Plan Numbers: 00497 00498 00500 09519 00501 00502 00478
Willamette Dental of Washington, Inc.
6950 NE Campus Way
Hillsboro, OR 97124
Plan Number: WA204
Standard Insurance Company
1100 SW 6th Avenue
Portland, OR 97204
Plan Number: 645273
VSP Vision Care, Inc.
3333 Quality Drive Rancho
Cordova, CA 95670
Plan Number: 30029829
First Choice Health EAP
600 University Street Suite 1400
Seattle, WA 98101
Metropolitan Life Insurance Company
200 Park Avenue
New York, NY 10166
Plan number unique to member.
Rehn & Associates
1322 N. Post Pl.
Spokane, WA 99201