Large Group Plan Options

Illinois Large Group Plan Documents

• Employer Group Application 2020 | 2019
• Employee Application (use when no claim experience) 2020 |2019
• Employee Application (use with claims experience) 2020 | 2019
• Employee Health Questionnaire 2020 | 2019
• Employee Census Template
• CMS Survey
• COBRA Group Continuation Notice
• Quartz Drug Formulary: $0 Copay List
• Quartz Drug Formulary: RX Outcomes List
• Domestic Partner Affidavit 2019 | 2020
• Waiver of Coverage 2019 | 2020

Get access to the information you need in one secure portal 

• Benefit / Member Information
• Quotes
• Tools
• Forms
• FAQs
• Secure messaging

To sign up, call or email Quartz Customer Service at (800) 362-3310.

Iowa Forms

• Iowa Employer Group Application
• Iowa Large Group Employee Application
• Iowa Waiver of Coverage
• Employee Census Form

Get access to the information you need in one secure portal 

• Benefit / Member Information
• Quotes
• Tools
• Forms
• FAQs
• Secure messaging

To sign up, call or email Quartz Customer Service at (800) 362-3310.

Minnesota Forms

• Minnesota Employer Group Application
• Minnesota Bill of Rights
• Minnesota Waiver of Coverage
• Employee Census Form

Get access to the information you need in one secure portal 

• Benefit / Member Information
• Quotes
• Tools
• Forms
• FAQs
• Secure messaging

To sign up, call or email Quartz Customer Service at (800) 362-3310.

New Large Group Forms

• Employer Group Application
• Employee Application (Use when no claims experience)
• Condensed Employee Application (Use with claims experience)
• New Group Checklist - Large Group
• Large Group Census Template

Existing Large Group Forms

• Employee Application for New Hires
• Waiver of Group Coverage Form
• COBRA Group Continuation Notice
• Quartz Drug Formulary: RX Outcomes List
• Quartz Drug Formulary: $0 Copay List

Get access to the information you need in one secure portal 

• Benefit / Member Information
• Quotes
• Tools
• Forms
• FAQs
• Secure messaging

To sign up, call or email Quartz Customer Service at (800) 362-3310.

Forms for Self-Funded Groups

• Appointment of Authorized Representative
• Benefit Lookup
• Explanation of Benefits Sample
• Enrollment Form
• Authorization for Disclosure of Protected Health Information Form
• Health Care Transition Form
• Participant Claim Form
• Quartz Stop Loss Proposal Request

As an Agent, MyPlanTools allows you to securely –

• View the group plan information for your agency clients, including Summary Plan Descriptions
• Create customized provider directories
• Email Quartz Customer Service
• View and confirm benefit eligibility

To sign up, call or email Customer Service at (800) 362-3310.