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Large Group

Enrollment Forms

Additional Forms

Employer Application – 2021 | 2020Large Group Creditable Coverage – 2021 | 2020 | Learn More
Employee Application (use when no claims experience) – 2021 | 2020Renewability and Rating Notice
Employee Questionnaire – 2021 | 2020   
Employee Census Template 
CMS Survey 
Waiver of Coverage Form – 2021 | 2020 
Domestic Partner Affidavit – 2021 | 2020    
Small Group

New Small Group Forms

Existing Group Forms

Illinois Small Group Employee Application/Change Form – 2021 | 2020  
Illinois CMS Survey
Illinois Small Group ACA Plans 2020  COBRA Group Continuation Notice
Employee Census TemplateIllinois Employer Group Application
 Illinois Small Group Creditable Coverage – 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 & Family Forms

Individual & Family Forms

Individual ApplicationPlan Options
English - 2021Quartz One - Standard PlanCSR Plan
Spanish - 2021  
Domestic Partner Affidavit 
Recurring Payment Form