Enrollment Forms

Ready to enroll in our dental or vision plans? Below you will find all the necessary insurance forms to do so. Remember, the first step to taking advantage of any WIBA/KIBC plan is to become a member.

In all cases, you will need to send the forms to the WIBA office. We will then direct the forms to the appropriate agency. You can fax the form(s) to 316-201-3268 or mail them to WIBA/KIBC Insurance at 200 E. 1st St., Ste. 101, Wichita, KS 67202.

For rate information or if you have any other questions, please call Karen Fillenworth, manager insurance services, at 316-201-3264 or email insurance@wiba.org.

Dental Insurance Forms
To enroll in the dental plan, you will need to fill out the following forms:

• Dental Group Enrollment

You will then need to fill out the following form, one for each person who is enrolling.

• Employee Enrollment Form

• Employer Enrollment Form

You will then need to fill out the following form, one for each person who is enrolling.

• Employee Enrollment Form

Change/Term Coverage Forms
At some point you many need to add or drop a dependent from your coverage, or maybe you need to drop coverage all together for someone. If this happens, you will need to fill out the following form(s).

• To change or terminate coverage through Preferred Health Systems, use for HMO, PPO or HDHP plans : Change/Term Form

• To change your Dental coverage: Dental Change Form(same as the enrollment form)

• To terminate your Dental coverage: Dental Term Form

• To change your Vision coverage: Vision Change Form(same as the enrollment form)

• To terminate your Vision coverage: Dental Term Form