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Apply for coverage from
Group Health Cooperative
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Enrollment Form
• Standard Health Questionnaire for use with coverage that begins on or after June 10, 2010 .
Application Process and Forms
To apply for any of the Group Health Cooperative individual
medical plans, please complete the following steps:
- Fill out the Application (one per
family)
Download the Group Health Cooperative
Individual/Family Enrollment Application. Print the
application and fill it out completely.
- Fill out the Questionnaire (one
for each person to be covered)
Download
the Standard Health Questionnaire for Washington State. Print and complete
the questionnaire for each person
to be covered on the plan. Please refer to Completing
the Health Questionnaire to determine
if this applies.
- Provide Proof of Washington State Residency
To be eligible to purchase this plan you must be a
Washington state resident.
A photocopy of one of the following must accompany
your application to prove residency:
- Valid Washington State Driver's License or Identification
Card
- Washington State Voter Registration Card
- Current Utility Bill in your name, including
address
- Provide Certificate of Creditable Coverage
(if available)
Please refer to Credit
for Prior Coverage & HIPAA Eligibility
for more information. Please note, if you do not have
your Certificate of Creditable Coverage at the time
of application, please submit your application anyway.
Credit for pre-existing condition waiting periods
will be credited upon receipt of your Certificate
of Creditable Coverage by Group Health Cooperative.
- Send a Payment
Payment of the first month's premium is required. You have a choice of automatic bank draft or credit card. The required forms are attached to the insurance application. Please complete one and submit it with the application packet.
- Send all Enrollment Materials to:
CDA Insurance LLC
P.O. Box 26540
Eugene, OR 97402
Please note: Group Health Cooperative
requires all COMPLETED enrollment materials
to be postmarked to their office on or before the 20th
of the month. Incomplete enrollments may cause delays
in the effective date of your coverage. Please refer to
the checklist on the application to avoid delays.
For Example: If you wanted your medical
insurance coverage to begin on April 1, you would need
to send all of the required, completed enrollment material
to Group Health Cooperative postmarked on or before March
20.
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