New Application

Please download and complete the application below.

Portable Healthcare Account (PHA) Enrollment Form

Once signed and completed applications must be returned by fax to 360-466-9110, or emailed to Incomplete or unsigned applications may cause delays in setting up your account. Please call our customer service department at 360-466-9100 with any questions.

After completing and submitting your application, please download this Employee Agreement containing important information regarding your account.
Employee Agreement