Follow the steps to successfully complete your form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out Section 1, Appellant information. Indicate whether you are an employee, former employee, dependent of an employee, or an applicant not currently enrolled in SEBB benefits. Complete your personal information including last name, first name, middle initial, Social Security number, date of birth, and contact details such as address and phone number.
3. If your appeal concerns other individuals, proceed to fill out Section 2 for Other enrollee information. Provide the last names, first names, middle initials, and Social Security numbers for any other enrollees involved in your appeal.
4. In Section 3, describe your request for review or appeal. Provide a detailed account of the situation leading to your appeal and outline the specific outcome you are seeking. Use additional pages if necessary.
5. Sign and date Section 3 to validate your request. Ensure you keep a copy of the completed form for your records.
6. Submit the completed form to your employer's payroll or benefits office, ensuring it is delivered within 30 calendar days of the decision you are appealing. If appealing to the SEBB Appeals Unit, complete Section 7 after receiving the employer's decision.
7. After filling out all required sections, choose to save your changes, download the form, print it, or share it as needed.

Get started on your document now by filling out the WA HCA 20-0161 online!