KHI Agents
> Forms > Under Age 65
Wellmark
Applications
| Date | Form | Description | Download |
| January 2011 | N53254 | Application for Individual Health, Dental, and Life Insurance | Link |
| January 2011 | N5428 | Individual Health Plan Contract Change | Link |
Rates
| Date | Form | Description | Download |
| April 2011 | Pool V Grandfathered Rates, Effective 4/1/2011 | Link | |
| April 2011 | M53845 | Pool V Grandfathered Optional Benefits Rates, Effective 4/1/2011 | Link |
| April 2011 | Pool V Non-Grandfathered Rates, Effective 4/1/2011 | Link | |
| April 2011 | M53845 | Pool V Non-Grandfathered Optional Benefits Rates, Effective 4/1/2011 | Link |
| April 2011 | Pool IV Grandfathered Rates, Effective 4/1/2011 | Link | |
| April 2011 | Pool IV Non-Grandfathered Rates, Effective 4/1/2011 | Link |
Short-Term Major Medical
| Date | Form | Description | Download |
| May 2009 | M5733 | Application for Short Term Major Medical Expense Policy | Link |
| August 2011 | M51945 | Outline of Coverage | Link |
| October 2009 | WBCBSI | Benefits Policy Short Term Major Medical, STMM Individual Version | Link |
| April 2011 | M53752 | Submission Cover Page (E-app Short Term) | Link |
Other
| Date | Form | Description | Download |
| January 2011 | N5707 | Direct Pay Information Change Request (Cancellation Form) | Link |
| September 2011 | M5779 | Automatic Payment Authorization (ACH) | Link |
| June 2009 | P5343 | Agent Authorization (HIPAA) | Link |
| April 2011 | M53750 | Submission Cover Page (E-app Under 65) | Link |
