To be eligible you must be a resident of one of the following Western Washington counties; Clark, King, Kitsap, Pierce, Snohomish, Island, Thurston, Whatcom, Skagit, San Juan, Mason, Lewis, and, Grays Harbor (zip codes 98541, 98557, 98554 and 98568). Eastern Washington counties: Kittitas, Yakima, Benton, Franklin, Walla Walla, Columbia, Whitman & Spokane. You must not be eligible for Medicare. Eligible dependents include your spouse/domestic partner and children under age 26. Children under age 19 may only be enrolled during a special open enrollment period determined by the state. For 2013 this period is now March 15th to April 30th and September 15th to October 31st. Exceptions include the birth or adoption of a child or if a child or their parent:
- is no longer eligible for a state program
- loses coverage due to a divorce
- loses employer-sponsored coverage
- moves and their plan is not available where they live
If you are enrolling a dependent under age 19 you must apply by mail (instructions).
Enrollment Forms & Instructions
Completed enrollment materials must be received in our office on or before 20th of the month to be effective on the first of the following month (e.g., June 20th for July 1st effective date).
- Complete the Group Health CooperativeEnrollment Application, check the box for dental coverage if you desire it, and review the Terms and Conditions document. Only one application is necessary per family.
- We strongly recommend that you complete the Electronic Funds Transfer Form as well so that monthly premiums are not missed by accident.
- Complete the Standard Health Questionnaire. A separate questionnaire must be completed for each enrolling family member unless:
- Under 19 years of Age: Contact the OIC Consumer Hotline at 1-800-562-6900 for information on special open enrollment periods (listed above under eligibility) for children under 19 and coverage options outside of the special enrollment
- Relocation: Applicant is applying within 90 days of having relocated within Washington State and the prior health plan is not available. Include a copy of a utility bill in your name from the prior address and a letter of verification from your prior carrier.
- Provider Cancellation: The applicant has exhausted all COBRA continuation coverage and is applying within 90 days of COBRA ending. Include a letter from the COBRA Administrator verifying that you have exhausted your COBRA benefits.
- COBRA Exhaustion: The applicant has exhausted all COBRA continuation coverage and is applying within 90 days of COBRA endingor you lost coverage due to your employer going out of business or discontinuing its health plan while you were on COBRA. Include a letter from the COBRA Administrator verifying that you have exhausted your COBRA benefits.
- Employer’s Plan Not Subject to COBRA: Applicant is applying within 90 days of losing coverage under an employer's plan that was not subject to COBRA coverage and you had at least 24 months of continuous group coverage before such loss. Include a letter of verification from the employer.
- COBRA Eligible: Applicant is applying within 90 days of an event which qualifies you for COBRA and you had at least 24 months of continuous group coverage prior to such event buy you chose not to take COBRA coverage. Include a letter of verification from your employer addressing your COBRA eligibility and a certificate of coverage for proof of 24 months of continuous coverage
- COBRA Termination – Applicant applying within 90 days of terminating your COBRA coverage and you had at least 24 months of continuous group coverage prior to termination. Include a letter of verification from your employer addressing your termination of COBRA and a certificate of coverage for proof of 24 months of continuous group coverage.
- Group Plan Discontinued Due to Business Closure: Applicant is applying within 90 days before or after an employer discontinues a group plan due to business closure and you had at least 24 months of continuous group coverage. Include a letter of verification from the employer and certificate of coverage.
- Loss of Basic Health Plan (BHP) Coverage: Applicant is applying within 90 days of losing coverage under the BHP and had at least 24 months of continuous BHP coverage before such loss. Include a letter of verification from the BHP.
- Addition of Newborn: Applicant is adding a newborn or newly adopted child to an existing policy within 60 days of birth, adoption or date of placement for adoption. Include copy of birth certificate/adoption papers.
- Submit your Enrollment Application and Standard Health Questionnaire to:
R. L. Evans Company, Inc.
3535 Factoria Blvd SE, Ste 120
Bellevue, WA 98006