PacificSource Forms
for Oregon
You're welcome to download the following administrative forms, or contact your regional marketing office to request hard copies. These forms can be completed online before printing; see our Q&A for more information.
Requesting
Quotes:
Proposal Request – Non-SEHI Groups
Proposal Request – SEHI Groups
Oregon Group Profile Form
Common Ownership Confirmation Form
Enrolling New Business:
For all groups:
Agent Checklist for New Groups
Request
for Group Insurance
Group
Health/Dental Enrollment*
Group Dental Enrollment (for dental-only clients)
Additional forms for FlexPerks HRAs:
Additional forms for integrated banking with HSA Bank:
HSA Employer Forms Packet - all required employer forms in a single file
HSA Member Enrollment Packet - all employee information and forms in a single file
Additional forms for Dual Option packages:
Plan Selection Form, Package 1
Plan Selection Form, Package 2
Plan Selection Form, Package 3
Plan Selection Form, Package 4
Plan Selection Form, Package 5
Plan Selection Form, Package 6
Additional forms for life and disability coverage:
Request for Group Life/Disability Insurance - agent and employer forms
Group Life/Disability Enrollment Packet - member forms
Administering
Existing Business:
Agent Commission Direct Deposit Authorization
Authorization to Use/Disclose PHI
Continuation Election – Dental Only
Continuation Election – Federal*
Continuation Election – State*
Continuation Initial Notice – Federal*
Disabled Dependent Certification
Employer Census for Client Size Determination
Provider Nomination Form - PacificSource Networks
Provider Nomination Form - First Health Network
*Spanish version available on our Spanish Materials page
Unless otherwise stated, all text and images © 2006 PacificSource. All rights reserved.