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The “Washington Individual Enrollment Application” and the “Standard Health Questionnaire for Washington State” are both required to be filled out unless you meet one of the exceptions for the health questionnaire. All required applications are marked with !
! Washington Individual Enrollment Application Please list all family members to be covered on this form unless you are enrolling separately.
! Standard Health Questionnaire for Washington State This questionnaire is required* for all individuals submitting applications in Washington State. Please print this form, fill it out, and submit it for each individual (including children) who is applying for insurance at this time. * The Standard Health Questionnaire for Washington State must be filled out by anyone applying for individual coverage unless they meet at least one of the following exceptions. Do not fill out this health questionnaire if any of the following apply to you:
- You have Medicare benefits.
- When a newborn, a child placed for adoption, or a newly adopted child regardless of age is being added to a parent’s existing policy, a health questionnaire does not need to be filled out for the child as long as the addition of the child is made within 60 days of birth, placement, or adoption.
- You are applying for medical insurance because you have used up all the available time on your “COBRA” coverage. In order for this exception to apply, you must submit your application to the new insurance carrier within 90 days from the date that COBRA coverage ended.
- Your former employer, who provided you with health coverage, has gone out of business while you were on “COBRA” coverage, and you are applying for medical insurance within 90 days from the date that coverage ended.
- You are applying for coverage with a new carrier because you have moved from one part of Washington State to another, and the insurance carrier that you had does not offer medical coverage where you live now. In order for this exception to apply, you must submit your new application to the new insurance carrier within 90 days from the time that you moved.
- You are applying for coverage with a new insurance carrier because your doctor or other health care provider has stopped being a part of the provider network on your current individual medical plan. In order for this exception to apply,
a) Your doctor or provider must be on the new plan you are applying for;
b) You must have had some service from that provider during the 12 months before he or she left your current plan, and;
c) You must submit your application to the new insurance carrier within 90 days from the day your provider left your current insurance carrier’s network.
d) This exception does not apply if provider access is lost because your insurance carrier is no longer available.
- You have lost, or will be losing, your group coverage from a health plan that is exempt from COBRA (provided under 29 U.S.C. 1161 et. seq.) and you had 24 months of continuous group coverage (including church plans) immediately prior to losing coverage, and you are applying for medical coverage no more than 90 days prior to when you will lose that group coverage or within 90 days after you lost it.
a) you must submit your application to the carrier within the period beginning 90 days before the “qualifying event”, and ending 90 days after the qualifying event (as defined under “COBRA");
- You were, or are still, enrolled in the Washington State Basic Health Plan (BHP) and had 24 months of continuous coverage under the Plan immediately prior to disenrollment, and you are applying for individual coverage no more than 90 days prior to when you will lose BHP coverage or within 90 days after you lost it.
! As proof of Washington state residency, include a photocopy of one of the following:
- Valid Washington State Driver’s License or ID
- Current Utility bill in your name and address of your current residence.
- Voter Registration Card
Please mail all forms and attachments to:
Gallagher Reppond
Attn: Reina Russell
777 108th Avenue NE
Suite 200
Bellevue, WA 98004
Applications must be received by Gallagher Reppond no later than the 19th of the month in order to ensure a first of the next month effective date.
Please contact Reina Russell if you have any questions:
425-451-8000 or 1-800-542-9000 or email at reina_russell@ajg.com.
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