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Tim Wiedman Associates
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Client Services for PHP
Forms for PHP: For additional infomation from PHP visit their website at

The following forms are for new groups setting up their plans. These should be returned to Tim Wiedman Associates:
Small Group Employee Application
Large Group (26+) Employee Application
Employer Application
Employer Dental Application

These forms are for established groups. After completing them, they should be faxed to PHP at (260) 969-2420. The first form is used when hiring a new employee. Be sure to complete it within the time allowed for your waiting period. If you do not remember your waiting period, please contact us or call PHP customer service at (800) 982-6257. Note that a new employee is not required to disclose any medical information. The second form is used when there is a change in status for an existing employee, such as new child, new spouse, divorce, etc.

Application for new employee small group
Employee Change form

Note: These forms are in Adobe Portable Document Format (PDF). In order to view PDF files, you will need the Adobe Acrobat Reader. The reader is available for downloading free of charge at