Enrollment Forms

Ready to enroll in one or more of our insurance programs? Below you will find all the necessary insurance forms to do so. Remember, the first step to taking advantage of any WIBA/KIBC plan is to become a member.

In all cases, you will need to send the forms to the WIBA office. We will then direct the forms to the appropriate agency. You can fax the form(s) to 316-267-8964 or mail them to WIBA/KIBC Insurance at 445 N. Waco, Wichita, KS 67202.

If you have questions, please call Karen Fillenworth, manager insurance services, at 316-267-8987 or email insurance@wiba.org.

Health | Dental | Vision |  Long-Term | Change/Term

Health Insurance Forms
No matter which plan you choose, you will need to fill out the following three forms:

• Contact Information Form
• Member Business Application
• Health Questionnaire (if enrolling during Open Enrollment, you do not need to fill out this form)

  Health Questionnaires must mail directly to the Preferred Health System offices. Please mail to:  
   

  Chad Patton Preferred Health Systems 8535 E. 21st St. N Wichita, KS  67206-2911

  
  
  
  

After filling out the forms, you will need to select the health insurance plan you would like and fill out the corresponding enrollment form (fill out one for each employee who is enrolling).

• HMO Enrollment
• PPO Enrollment
• HDHP/HSA Enrollment
  

Don’t forget, if you choose the HSA plan, you will also need to open a Health Savings Account through the bank of your choice. We recommend using a WIBA Member bank…find one by using our Membership Directory.

For the Limited Benefit plan you will need the following forms:

• Employer enrollment form
• Employee enrollment form
  And if 20 or more employees you will also need
• Cobra Service Agreement

Dental Insurance Forms
To enroll in the dental plan, you will need to fill out the following forms:

• Dental Group Enrollment
  

You will then need to fill out the following form, one for each person who is enrolling.

• Employee Enrollment Form

Vision Insurance Forms
To enroll in the Surency Vision product fill out the following forms:

• Employer Enrollment Form

You will then need to fill out the following form, one for each person who is enrolling.

• Employee Enrollment Form

Long-Term Care
To sign up for long-term care, you will need to contact David Landwehr at LT Care Solutions directly. David Landwehr, long-term care specialist, 316-733-1820.

Change/Term Coverage Forms
At some point you many need to add or drop a dependent from your coverage, or maybe you need to drop coverage all together for someone. If this happens, you will need to fill out the following form(s).

• To change or terminate HMO coverage: HMO Change/Term Form
• To change or terminate PPO coverage: PPO Change/Term Form
• To change or terminate HDHP/HSA coverage: HDHP/HSA Change/Term Form
• To change your Dental coverage: Dental Change Form (same as the enrollment form)
• To terminate your Dental coverage: Dental Term Form
• To change your Dental coverage: Vision Change Form (same as the enrollment form)