WHIT Forms

WHIT provides cost effective employee benefit plans

FORMS

WHIT and DiMartino Associates, Inc. are happy to work with participating groups' benefits consultants and/or insurance brokers. Please have your representative contact us for further information.

206-467-9408 (Seattle)
1-888-715-8000

	Cascade Medical Center Cascade Valley Hospital and Clinics Central Washington Hospital Columbia Basin Hospital East Adams Rural Hospital Enumclaw Regional Hospital Ferry County Memorial Hospital Garfield CountyPublic Hospital District Grays Harbor Community Hospital Harrison Medical Center Highline Medical Center Island Hospital Jerfferson General Hospital Kadlec Medical Center Kennewick General Hospital Kittilas Valley Community Hospital Lake Chelan Community Hospital Lincoln Hospital Mark Reed Hospital Mason General Hospital Mattawa Community Medical Clinic McKay Memorial Hospital Mid-Valley Hospital Morton General Hospital MultiCare Health System Neurological Center North Valley Hospital Ocean Beach Hospital Okanogan Douglas District Hospital Olympic Medicaal Centrer Othello Community Hospital Prosser Memorial Hospital Pullman Regional Hospital Quincy Valley Hospital Samaritan Healthcare Skagit Valley Hospital Stevens Healthcare Sunnyside Community Hospital United General Hospital Whidbey General Hospital Whitman Hospital and Medical Center Willapa Harbor Hospital

Please click on the document links below to open the required form. To save a document to your personal computer: right click on the document hyperlink, select "Save Target As" from the dropdown list and then specify where you would like to save the document.

Last Updated: February 21, 2008


...	WHIT Subscription Agreement
...	Summary Plan Description


...	Washington Dental Service Application
...	Washington Dental Service Enrollment Form
	Willamette Dental Enrollment Form


...	Group Vision Care Application


	Before March 1, 2008
...	Designation of Beneficiary
...	Group Life Conversion Application
...	Proof of Loss Claim Statement
...	Long Term Disability & Group Life Waiver of Premium Benefits
...	Preliminary Plan Application
...	Confirmation of Plan Application

	After March 1, 2008
...	Life Claim Form
...	Life Conversion Request Packet
...	Waiver of Premium Form


	Before March 1, 2008
...	Long Term Disability & Group Life Waiver of Premium Benefits
...	Preliminary Plan Application
...	Confirmation of Plan Application

	After March 1, 2008
...	LTD Claim Form
...	LTD Conversion Card


...	Death Claim Form
...	Notice of Continutation of Group Term Life Insurance
...	Beneficiary Designation Change
...	Claim for Total Disability Benefits - Employer
...	Claim for Total Disability Benefits - Employee
...	Policy Profile
...	Attending Physicians Statement
...	Request for Group Insurance

WHIT provides unique benefit plans to its members

For all information regarding benefit levels, pricing or to request a quote, please contact Karni Adamson or Cricket Morgan at DiMartino Associates, Inc.

206-467-9408 (Seattle)
1-888-715-8000

WHIT serves hospitals and healthcare related groups in the Pacific northwest

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	Before March 1, 2008
...	Preliminary Plan Application
...	Confirmation of Plan Application
...	Personal Accident Enrollment Card

	After March 1, 2008
...	Stand Alone AD&D Enrollment and Beneficiary Form
...	Life/AD&D Beneficiary Form
...	AD&D Claim Form


...	AHA Short Term Disability Rates Calculator
...	AFA New Business Submission Form
...	AFA New Business Data Sheet
...	AFA Subscription Agreement

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