Wichita Independent Business Association
Insurance Main | Health | Dental | Vision | Prescription Drug Coverage | Long-Term Care | Enrollment Forms
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Health Insurance
Dental Insurance
Vision Insurance
Prescription Drug Coverage
Long-Term Care
 
Enrollment Forms

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 | Prescription | Long-Term | Change/Term

 


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

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).

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:


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

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


Vision Insurance Forms
For the vision plan, you can either enroll one person (individual or family) or you can enroll two or more people and be a group. In either case you will need the following two forms: 

To enroll on line click here! 


Prescription Plan Forms
For the prescription plan, you can either enroll as a Sole Proprietor or as a Group (2 or more employees). Please note, with the prescription plan, you will need to send a check made payable to MaxorPlus for your first month’s premium along with the enrollment form(s).


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).

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