Forms

2025 Plan Year Monthly Funding Rates

7/1/2025 – 6/30/2026

Flexible Spending Account (FSA) Plans

You must see a Washington National rep to enroll in the FSA and Dependent Care Accounts. Note: Your elections for these plans do NOT carry over to the new plan year. You MUST make an active election to continue these deductions.

Election Form

CLICK HERE TO VIEW ELECTION FORM

This form is used for:

Employees enrolling in medical, dental or vision coverage for the first time
If you are already enrolled in a plan and want to change your election or add/delete dependents then use the Change Form
Note that a spouse will NOT be added until both pages of the Spousal Eligibility Certification form are completed and sent to Sandy Harrell at [email protected] by June 30

Change Form

Note that you must provide a birth certificate (when adding a dependent) or marriage license and Spousal Eligibility Certification form (when adding a spouse). These items should be sent to Sandy Harrell at [email protected] by June 30.

CLICK HERE TO VIEW CHANGE FORM

This form is used for:

Change coverage (i.e., switch to a different medical plan)
Drop coverage (i.e., terminate your medical coverage)
Add a spouse or dependent
Drop a spouse or dependent
Update your address
Make a name change due to marriage or divorce (Note that you will be required to provide a Social Security card as proof of the name change)
Note that a spouse will NOT be added until both pages of the Spousal Eligibility Certification form are completed and sent to Sandy Harrell at [email protected] by June 30

Other Insurance Coverage Form

CLICK HERE TO VIEW OTHER INSURANCE COVERAGE FORM

This form is used:

Whenever an employee enrolls in the medical plan for the first time on the Election Form
Whenever a spouse or dependent is added to the medical plan for the first time using the Change Form
A form must be completed whether or not you, your covered spouse or covered dependents have other coverage
The Other Insurance Coverage form is NOT needed for dental or vision coverage
If there is no other coverage, then just answer the question, Does your Spouse or Dependents have other coverage?, “No” then sign and submit the form.

Spousal Eligibility Certification Form

CLICK HERE TO DOWNLOAD THE FORM

This form is used:

Whenever a spouse is covered on the medical plan
It does not need to be completed if the spouse is not employed
The second page of the form must be completed by the spouse’s employer
If the spouse is self-employed then the spouse completes the form himself/herself
A new form must be completed every year by June 30 every year
The spouse will NOT be added until both pages of the Spousal Eligibility Certification form are completed and sent to Sandy Harrell at [email protected] by June 30

HIPAA Notice of Special Enrollment Rights

CLICK HERE TO DOWNLOAD THE FORM

Download this PDF file so you can keep a copy for your records.

This attestation is included in the signature statement for the following forms:

Election Form
Change Form