Illinois Forms

Group Product Forms

Enrollment Forms

Additional Forms

Employer Application – 2019 | 2020Quartz Drug Formulary: $0 Copay List
Employee Application Form (use with claims experience) – 2019 | 2020Quartz Drug Formulary: Rx Outcomes List
Employee Application (use when no claims experience) – 2019 | 2020Small Group ACA Plans 2019 | 2020
Employee Questionnaire – 2019 | 2020Small Group Creditable Coverage – 2019 | 2020 | Learn More
Employee Census TemplateLarge Group Creditable Coverage – 2020 | Learn More
CMS Survey 
Waiver of Coverage Form 2019 | 2020 
Domestic Partner Affidavit 2019 | 2020 
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