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LEGACY MEDICAL GROUP MASTER APPLICATION FOR <br />WCIF 2017 WCIF COVERAGE <br />Attach separate sheets of paper if additional space is necessary. Plan summaries and other information <br />WASHING T o ra c ; u �d r E 5 y <br />1PISURANCE Fus® may be found at www.wcif.net > Plan Information. <br />Coverage Effective Date:01/01/17 <br />This is an application for (check one): <br />® Annual Renewal ❑ New Participating Employer <br />❑ Mid -Year Plan Change ❑ Existing Employer, New Division <br />If submitting multiple applications for SUBGROUPS: <br />(Note: Employees with different benefits (i.e. subgroups) require a separate Group Master Application) <br />Application Number: (i.e. "1 of 3') Subgroup Name: (i.e. "Health Dept.," "Union," etc.) <br />1 of 3 All Except Line and Probation <br />Kittitas County <br />Doing Business As (DBA): <br />By what name would you prefer <br />WCIF to refer to your oganization? <br />® Legal Name ❑ DBA Name <br />Business Physical Address: (No PO Box orPMB) City: State: Zip: County: <br />205 W 5th Avenue Ellensburg WA 98926 Kittitas <br />Business Mailing Address: (if different from physical) City: State: Zip: County: <br />Federal Tax ID Number: BSI Account Number (assigned by BSI) Is your organization a public entity? <br />91-6001349 58 ® Yes ❑ No <br />What type of entity is your organization? (check only ONE box) <br />#1 ® County <br />#2 ❑ Other local government entity (includes all taxing districts) <br />#3 ❑ Non-profit organization receiving state or local government funding <br />NOTE: Organizations that check only #3 must provide proof of funding with this application. <br />#4 ❑ Other: <br />COMMISSIONER / EXECUTIVE DIRECTOR / CEO (etc.) <br />Name & Title: Phone: Fax: <br />Obie O'Brien, Commissioner 509-962-7508 <br />Email: <br />obi e.obrien@co.kittitasma.us <br />WCIF INSURANCE ADVISORY COMMITTEE (IAC) DESIGNEE (voting member) <br />IAC members are initial points of contact for plan changes, renewal information and the WCIF voting member of the group. <br />Name & Title: Phone: Fax Email: <br />Obie O'Brien, Commissioner 509-962-7508 obie.obrien@co.kittitas.wa.us <br />GROUP BENEFITS ADMINISTRATOR (Administrators' Committee for Excellence (ACE) Designee) <br />ACE member will be the primary contact for WCIF plan benefit updates and administration. <br />Name & Title. Phone: Fax: Email: <br />Lisa Young, HR Director/Risk Manager 509-962-7084 lisa.young@co.kittitas.wa.us <br />GROUP BILLING ADMINISTRATOR (Administrators' Committee for Excellence (ACE) Designee) <br />ACE member will be the primary contact for WCIF plan billing updates and administration. <br />Name & Title: Phone: Fax: Email: <br />Judy Pless, Budget & Finance Manager 509-962-7502 judy.pless@co.kittitas.wa.us <br />INSURANCE PRODUCER (as applicable) <br />Does your organization use an insurance producer for WCIF plans? ❑ Yes (if YES, complete the following) ❑ No <br />Producer Name: Phone: Fax: Email: <br />2017LMGMA2 Page 1 of 9 (092116JM) <br />