To apply for coverage, complete the enrollment application and standard health questionnaire (SHQ).  One SHQ is required for each family member.  To prove Washington residency, you must include a photocopy of your drivers license (primary insured only) or a utility bill.  Mail all items to Green Financial.  Please include a check for the first month premium (payable to KPS Health Plan) with your application.  If you are not approved for coverage, your check will be returned.

Applications must be received by the 19th of the month to be considered for an effective date for the first of the following month.

Choice 1: Select the Adobe PDF version and print
Choice 2: Select Online version, complete online (yellow area), then print

In either case, it is required you print and sign the forms and return with required items.

Part 1
Enrollment Application - PDF Form (160KB pdf)
Enrollment Application Online Choose open, then OK. Complete all three pages.

Part 2
Standard Health Questionnaire - PDF Form (242KB pdf, 23 pages)
Standard Health Questionnaire - OnlineChoose open, then OK. Complete all 23 pages.

Remember, one health questionnaire for each family member.  Although this form has 280 questions it is much easier to complete than it appears.  There are only 13 main sections (A through M). Answering "no" to any of the main questions allows you to skip the questions in that particular section.

If you prefer we can fax, mail, or e-mail these forms to you.  Either call us at 800-877-8019 or go to Home, Contact us and request. You'll need Acrobat Reader to display the PDF files.  If you don't have that program, you can download it free from Adobe.