Individual Product Forms

• Application and cover sheet (PDF) for Regence Summit^SM, Regence NowSelect and the Regence Individual Health Savings Account (effective 1/1/08)
• Application Update Form (PDF)
• Application for Protection Plus Plan (PDF) (Washington)
• Proxy Notice (PDF)
• Parental Consent Form (PDF)
• Multiple Coverage Inquiry Form (PDF)
• Automatic Withdrawal Form (PDF)
• Policy Change Request (PDF)
• Washington Deductible Change Form (PDF)
• Request to Add a Newborn to Your Policy (PDF)

Medicare Product Forms

• Application for Medicare Supplement and Senior Selection (PDF)
• Policy Change Request Form for Medicare Supplement and Senior Selection (PDF)
• Application for HealthSense 65 (PDF)
• Enrollment Forms
  • Regence MedAdvantage
  • Regence Life and Health Medicare Script
• Short Enrollment Forms - for existing members to upgrade their plan
  • Regence MedAdvantage
  • Regence Life and Health Medicare Script

Group Product Forms

• HSA Dual Option Matrix (PDF) (effective 1/1/08)
• Idaho Group Proposal Request Form (PDF) (2-50 and 51-99 Eligible Employees)
• Small Group Application (PDF) (2-50 Eligible Employees)
• Large Group Application for Enrollment (PDF) (Experience-rated or ASC)
• Application for Enrollment (PDF) (51-99 employees)
• Group Master Application (GMA) (2-99 employees)
• Waiver Form (Group Size 2-50)
• Employee Certification (PDF)
• Multiple Coverage Inquiry Form (PDF)
• Agent Letter of Record (PDF)
• Willamette Dental Group Application (PDF)
• Willamette Dental Enrollment and Change of Information (PDF)
• Request to Add a Newborn to Your Policy (PDF)

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