WHIT Forms | Brokers and Consultants | 206-467-9408

Last updated November 11, 2023

WHIT
Master Participation Agreement (long form)
Master Participation Agreement (short form)
Master Renewal Agreement
Universal WHIT Employee Enrollment & Change Form
Quick Reference Guide for WHIT Employers
Summary Plan Description

DENTAL
Master Participation Agreement (long form)
Master Participation Agreement (short form)
Master Renewal Agreement
Universal WHIT Employee Enrollment & Change Form

VISION
Master Participation Agreement (long form)
Master Participation Agreement (short form)
Master Renewal Agreement
Universal WHIT Employee Enrollment & Change Form

BASIC LIFE/AD&D
The Standard Life Claim Form
The Standard Life/AD&D Beneficiary Form
The Standard Life Conversion Request Packet
The Standard Waiver of Premium Form
The Standard AD&D Claim Form
Standard Insurance Company Additional Life Portability Form

LONG TERM DISABILITY
The Standard LTD Claim Form
The Standard LTD Conversion Form

VOLUNTARY SUPPLEMENTAL LIFE
Medical History Statement
Death Claim Form
The Standard Probability Form

VOLUNTARY AD&D
The Standard Stand Alone AD&D Enrollment and Beneficiary Form
The Standard AD&D Claim Form

EXISTING WHIT PARTICIPATING GROUPS OR MEMBERS
To request benefit or rate information specific to your coverage or a copy of your current policy, please email Ashton Alvarez.

For all information regarding benefit levels, pricing or to request a quote, please contact Ashton Alvarez at DiMartino Associates 206-812-7535 (Seattle) 888-715-8000.

WHIT is an employer welfare benefit plan and serves hospitals and other health care related entities across the United States Pacific Northwest.

WHIT was established to provide unique and cost-effective employee benefit plans to its members. This continues to be the criteria we use when evaluating new products and/or carriers. The products in WHIT must provide something the hospitals and healthcare related groups cannot obtain on their own.

Public and private hospitals located in the Pacific Northwest are eligible for participation in the Trust, as well as other employers in the health care industry with a minimum of ten employees.

Employee benefits consultant DiMartino Associates and WHIT are happy to work with participating groups' benefits consultants and/or insurance brokers. Please have your representative contact us at 206-812-7535 (Seattle) 888-715-8000 or email us at WHIT for further information.

FORMS