Apply for coverage from Group Health Cooperative
GHC Home | GHC Enrollment Form

• Standard Health Questionnaire for use with coverage that begins on or after July 21, 2011.

Application Process and Forms

To apply for any of the Group Health Cooperative individual medical plans, please complete the following steps:

1. Fill out the Application (one per family)
   Download the Group Health Cooperative Individual/Family Enrollment Application. Print the application and fill it out completely.
   
   
2. Fill out the Questionnaire (one for each person to be covered)
   Download the Standard Health Questionnaire for Washington State. Print and complete the questionnaire for each person to be covered on the plan. Please refer to Completing the Health Questionnaire to determine if this applies.
   
   
3. Provide Proof of Washington State Residency
   To be eligible to purchase this plan you must be a Washington state resident.
   A photocopy of one of the following must accompany your application to prove residency:
   
   • Valid Washington State Driver's License or Identification Card
   • Washington State Voter Registration Card
   • Current Utility Bill in your name, including address
   
   
4. Provide Certificate of Creditable Coverage (if available)
   Please refer to Credit for Prior Coverage & HIPAA Eligibility for more information. Please note, if you do not have your Certificate of Creditable Coverage at the time of application, please submit your application anyway. Credit for pre-existing condition waiting periods will be credited upon receipt of your Certificate of Creditable Coverage by Group Health Cooperative.
   
   
5. Send a Payment
   Payment of the first month's premium is required. You have a choice of automatic bank draft or credit card. The required forms are attached to the insurance application. Please complete one and submit it with the application packet.
   
   
6. Send all Enrollment Materials to:
   CDA Insurance LLC
   P.O. Box 26540
   Eugene, OR 97402