Employee Applications/Enrollment 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.
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.
Annual Employer Audit:
All employers must complete this form.
Use this form if we have requested accident information from you regarding a claim.
Electronic Payment Authorization Forms:
HIPAA Authorization for Release of Information:
Use this form if you need to give us authorization to request or release your protected health information.
COBRA Initial Notice (PDF)