Enrollment Forms | Additional Forms |
Employer Application – 2020 | 2021 | Large Group Creditable Coverage – 2020 | 2021 | Learn More |
Employee Application (use when no claims experience) – 2020 | 2021 | Renewability and Rating Notice |
Employee Questionnaire – 2020 | 2021 | |
Employee Census Template | |
CMS Survey | |
Waiver of Coverage Form 2020 | 2021 | |
Domestic Partner Affidavit 2020 | 2021 |
New Small Group Forms | Existing Group Forms |
Illinois Small Group Employee Application/Change Form – 2020 |
2021 | Illinois CMS Survey |
Illinois Small Group ACA Plans 2020 | COBRA Group Continuation Notice |
Employee Census Template | Illinois Employer Group Application |
Illinois Small Group Creditable Coverage – 2020 | 2021 | Learn More | |
Quartz Drug Formulary: $0 Copay List | |
Quartz Drug Formulary: Rx Outcomes List | |
Quartz High-Deductible Health Plan $0 Safe Harbor Drug List | |
Renewability and Rating Notice |
Individual Application | Plan Options |
English - 2021 | 2020 | Quartz One - Standard Plan | CSR Plan |
Spanish - 2021 | 2020 | Performance Network - Standard Plan 2020 | CSR Plan 2020 |
Domestic Partner Affidavit |