Forms

Employer Applications:

Nevada Employer Application (PDF)
Use this form if you are an employer in Nevada that is applying for group coverage.

Other States Employer Application (PDF)
Use this form if you are an employer in Arizona, Idaho, Montana or Utah that is applying for group coverage.

Annual Employer Audit (PDF)
All employers must complete this form.


Employee Applications/Enrollment Forms:

Arizona
You must complete this form.
Employee Application (PDF)

Idaho
You must complete this form.
Employee Application (PDF)

Montana
You must complete this form.
Employee Application (PDF)

Nevada
You must complete this form.
Employee Application (PDF)


Utah
You must complete this form.
Employee Application (PDF)


Other Forms:

Employee Change of Status Form
Use this form if you need to change your name, you need to add or delete dependents, or you need to change your beneficiary.
Change of Status Form (PDF)

Coordination of Benefits Form:
Use this form to let us know if you or any of your dependents are currently covered under any other health insurance policy in addition to your coverage with WMI Mutual Insurance Company.
Coordination of Benefits Information (PDF)

Accident Claims:
Use this form if we have requested accident information from you regarding a claim.
Accidental Injury Information Request (PDF)

HIPAA Forms:
Use this form if you need to give us authorization to request or release your protected health information.
HIPAA Authorization for Release of Information (PDF)

COBRA Forms:
COBRA Initial Notice (PDF)
COBRA Notice of Qualifying Event (PDF)