Form SI16119 (377661-B) Medical History Statement (Evidence of Insurability) - Public Employees Benefits Board (Pebb) Program - Washington

What Is Form SI16119 (377661-B)?

This is a legal form that was released by the Washington State Health Care Authority - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form SI16119 (377661-B)?
A: Form SI16119 (377661-B) is the Medical History Statement (Evidence of Insurability) for the Public Employees Benefits Board (PEBB) Program in Washington.

Q: What is the purpose of Form SI16119 (377661-B)?
A: The purpose of Form SI16119 (377661-B) is to gather information about an individual's medical history as a part of their evidence of insurability for the PEBB Program.

Q: Who needs to fill out Form SI16119 (377661-B)?
A: Employees who are enrolling for insurance coverage through the PEBB Program in Washington are typically required to fill out Form SI16119 (377661-B).

Q: Are there any instructions for filling out Form SI16119 (377661-B)?
A: Yes, instructions for filling out Form SI16119 (377661-B) are usually provided along with the form itself. It is important to carefully follow the instructions to ensure accurate completion of the form.