Illinois Forms

Large Group

Enrollment Forms

Additional Forms

Employer Application – 2019 | 2020Large Group Creditable Coverage – 2020 | Learn More
Employee Application (use when no claims experience) – 2019 | 2020 
Employee Questionnaire – 2019 | 2020
Employee Census Template 
CMS Survey 
Waiver of Coverage Form 2019 | 2020 
Domestic Partner Affidavit 2019 | 2020 
Small Group

New Small Group Forms

Existing Group Forms

Illinois Small Group Employee Application Form – 2019 |  2020
Illinois CMS Survey
Illinois Small Group ACA Plans 2019 |  2020 COBRA Group Continuation Notice
Employee Census TemplateIllinois New Hire Application/Change Form
 Illinois Small Group Creditable Coverage – 2019 |  2020 | Learn More

Quartz Drug Formulary: $0 Copay List
 Quartz Drug Formulary: Rx Outcomes List
 Quartz High-Deductible Health Plan $0 Safe Harbor Drug List
Individual & Family Forms

Individual & Family Forms

Individual ApplicationPlan Options
English - 2020 | 2019Performance Network Standard Plans - 2020 | 2019
Spanish - 2020 | 2019Performance Network CSR Plans - 2020 | 2019
Recurring Payment Authorization Form