Illinois Forms + Resources

Enrollment Forms

Employer Group Application – 2022 

Employee Application – 2022 
(use when no claims experience)

Employee Questionnaire – 2022 

Employee Census Template

CMS Survey

Waiver of Coverage Form – 2021 

Domestic Partner Affidavit – 2021 

Additional Forms

Large Group Creditable Coverage – 2022 | Learn More

Renewability and Rating Notice

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