WESTERN HEALTHCARE INSURANCE TRUSTWestern Healthcare Insurance • September 1st, 2023
Annual Renewal Effective Date: 01/01/2024 Vimly Account Number (INTERNAL USE): 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 Domestic Partners? YES NO We allow the following Domestic Partnerships. Same Sex Opposite Sex 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 Agency Name: Producer Name: Phone: Agency Address: City: State: Zip: PRODUCER SIGNATURE: DATE: COBRA An
