NWtech Employer Forms Library

The following forms are provided for your assistance in administering your group's health plan with NWtech. If you need assistance in completing any of these forms, please contact your agent or broker.

Please note: NWtech cannot accept an enrollment application that is for an incorrect effective date or carrier (Premera Blue Cross PBC or LifeWise Health Plan of WA LWHPW - for those groups located in Clark County.) Please ensure that you are using the correct forms.

Premera Blue Cross Forms - NOT Located in Clark County
Form Description	Form
NEW! 2010-11 PBC Employee Enrollment Application PBC Employee Enrollment Application for new and renewing groups with group effective dates of April 1, 2010 through March 1, 2011.	English Version Spanish Version
2009-10 PBC Employee Enrollment Application PBC Employee Enrollment Application for new and renewing groups with group effective dates of April 1, 2009 through March 1, 2010.	Click Here
Request for Certification of Overage Dependent For requesting certification of an overage (25+ years) dependent. See your medical benefit booklet for more information.	Click Here
Waiver of Coverage Form When the employer contribution for the employee premium is less than 100%, employees may waive coverage as long as the total enrollment for the group does not drop below 75%. (Note: In calculating this percentage, include all eligible employees, even if they have coverage elsewhere.	Click Here
Deductible Credit Form NWtech will credit amounts (for NEW groups only - not for individuals coming onto an existing NWtech plan) that were applied toward the calendar year deductible on the previous insurance plan toward the calendar year deductible on the new NWtech program.	Click Here
PBC RX Mail Order Form	Click Here
PBC RX Claim Form	Click Here
PBC Medical Dental Claim Form	Click Here
LifeWise Health Plan of WA Forms - Clark County Only
NEW! 2010-11 LWHPW Employee Enrollment Application PBC Employee Enrollment Application for new and renewing groups with group effective dates of April 1, 2010 through March 1, 2011.	English Version Spanish Version
2009-10 LWHPW Employee Enrollment Application PBC Employee Enrollment Application for new and renewing groups with group effective dates of April 1, 2009 through March 1, 2010.	Click Here
LWHPW RX Mail Order Form	Click Here
LWHPW RX Claim Form	Click Here
LWHPW Medical Dental Claim Form	Click Here
Waiver of Coverage Form When the employer contribution for the employee premium is less than 100%, employees may waive coverage as long as the total enrollment for the group does not drop below 75%. (Note: In calculating this percentage, include all eligible employees, even if they have coverage elsewhere.	Click Here
Deductible Credit Form NWtech will credit amounts (for NEW groups only - not for individuals coming onto an existing NWtech plan) that were applied toward the calendar year deductible on the previous insurance plan toward the calendar year deductible on the new NWtech program.	Click Here
Life and Disability Forms
Spousal Consent Form Use this form for Employees who do not wish to list their spouse as the named beneficiary on the group life plan.	Click Here
Supplemental Life Insurance Enrollment Form Use this form for employees who wish to apply for Supplemental Life Insurance.	Click Here
Life/AD&D Claim Form Use this form when a filing a Life or AD&D (Accidental Death and Dismemberment) claim.	Click Here
Life Insurance Conversion Form	Click Here
Dismemberment Claim Form	Click Here
Accelerated Death Form	Click Here
Domestic Partnership Forms
Affidavit of Domestic Partnership Employees that wish to add their domestic partners for insurance coverage whose partnership is not registered in the domestic partner registry of any state, should complete the appropriate form which should be retained by the employer for his/her records. The employee should also submit an employee application indicating the addition to BSI.	Click Here
Statement of Termination of Domestic Partnership Employees that wish to delete their domestic partner from their insurance coverage because the domestic partnership has been terminated should complete this form which should be retained by the employer for his/her records.	Click Here
Domestic Partner Q&A's Domestic Partner Q&A's.	Click Here
Administrative Forms
COBRA Agreement Find your COBRA Administration forms here.	Click Here
Employer Name or Tax ID Change Form Use this form to communicate a change to Employer name, DBA, tax ID or industry	Click Here
Review Forms
Request for Review Form NWtech has established procedures for employers to request a review of any decision involving eligibility, enrollment and disenrollment, probationary periods, late payment, reinstatement and similar issues involving day to day administration of NWtech. NOT FOR MEDICAL CLAIMS. See Group Administrative Guide for more information.	Click Here