AGC Health Plan of Washington

Broker Documents and Forms

If you have questions about obtaining an RFP or becoming an exclusive appointed broker, contact our broker relations department:

(971) 255-5359 or (866) 873-6175

General Forms and Documents			Back to Top
AGCWA Broker Administrative Guide 2011-12 Underwriting Guidelines 2011-12 Renewal Booklet Medicare Secondary Payer / TEFRA Explanation AGC Association Membership Information AGC of Washington Chapter (Western and Central WA) Membership Fact Sheet AGC Inland Northwest Chapter (Eastern WA) Membership Fact Sheet	Enrollment/Change/Waiver Form Approved SIC Codes		Medical Plan Comparison Program Highlights BSI Reference Guide AGC Health Plan for Washington State – Marketing Materials 2011 Single Page Flyer - AGC of Washington
New Group Submission Forms			Back to Top
New Group Submission Forms New Group Checklist Master Application Individual Health Statements Late Submission Application/Letter (If submission received after 20th) HN Ongoing Care Form (Optional) HN Waiver Form (Optional) Authorization for Disclosure of "R" Numbers (Optional)		BSI EFT Form BSI COBRA Agreement (Groups of 20+)
Proposal Request Forms			Back to Top
RFP Form Group Census Form	Group Health Risk Questionnaire Individual Health Statements
Renewal Forms
2011-12 Renewal Application	2011-12 Renewal Booklet