Common Contracts
1 similar Master Participation Agreement contracts
WESTERN HEALTHCARE INSURANCE TRUSTMaster Participation Agreement • September 5th, 2023
This is an application for (check one):Annual Renewal Existing Employer Change New Participating Employer Effective Date: Vimly Account Number (Internal Use Only): SECTION I: GROUP INFORMATION EMPLOYER INFORMATION Legal Name of Business Doing Business As (DBA) Business Physical Address City: State: Zip: Mailing PO Box City: State: Zip: Federal Tax ID Number State of Legal Domicile Type of Legal Entity Tax Exempt: YES NO Governmental Entity: YES NO Does your group cover Non-Registered YES NO Domestic Partners? We allow the following Same Sex Opposite Sex Domestic Partnerships. Both Group Benefits Administrator (This contact will be the primary contact for benefit updates and administration) Name & Title Phone: Email: Group Billing Administrator (This contact will be the primary contact for billing updates) Name & Title Phone: Email: Insurance Producer (as applicable) Does your organization use an insurance producer for WHIT plans? YES (if YES, complete the following) NO Ag
