Forms 

Benefit Choice

• FY2014 Benefit Choice Election Form

Address Change

• Address Change and Other Address/Addressee Information (PDF 26KB)

Beneficiary Forms

• Deferred Compensation (PDF 8 KB)
• Group Life Insurance Program (PDF 136 KB)
• Retirement System

Commuter Savings Program (CSP)

• CSP Claim Form [PDF 98, KB]

Dental Coverage

• Delta Dental of Illinois Claim form for claims beginning July 1, 2011

Dependent Certification

• Eligibility Certification Statement (PDF 24 KB)

Domestic Partner

• Termination of Group Insurance Coverage for Domestic Partner

Enrollment/Change Forms

• Part-time Employee Election/Waiver of Group Insurance Participation (PDF 116KB) Part-time Employee working 50% or greater use only
• Group Insurance Enrollment/Change Form (PDF, 258KB) – Employees use only (retirees and survivors must contact their retirement system)

Flexible Spending Accounts (FSA) Program

• FY2014 DCAP Enrollment Form - use this form if enrolling during the FY14 Benefit Choice Period
• FY2014 MCAP Enrollment Form - use this form if enrolling during the FY14 Benefit Choice Period
• FY2013 DCAP Enrollment Form (PDF 42 KB) - use this form if enrolling for FY13 plan year
• FY2013 MCAP Enrollment Form (PDF 44 KB) - use this form if enrolling for FY13 plan year
• DCAP Change in Status Form (PDF 19 KB)
• MCAP Change in Status Form (PDF 20 KB)
• Check Remittance Form (PDF 80 KB)
• FSA Claim Form (PDF 900 KB)  
• FBMC Direct Deposit Form (PDF 83 KB)
• MCAP COBRA Election Form (CMS-334) [PDF, 115KB]

Health Coverage

• Cigna Claim Form for QCHP (PDF 24 KB)

Leave of Absence

•  Leave of Absence Waiver

Life Insurance

• Beneficiary Form (PDF 136 KB)
• Conversion Application (PDF 79 KB)
• Election of Portability (PDF 79 KB)
• Statement of Health Application (PDF 145 KB)

Opt Out & Waiver Forms

• Opt Out Election Certificate (PDF 27 KB) - Full-time Employee, Annuitant and Survivor use only
• Opt Out Election Certificate with Financial Incentive (PDF 20 KB) - Non-Medicare SERS Annuitant use only
• Part-time Employee Election/Waiver of Group Insurance Participation (PDF 116KB) - Part-time Employee working 50% or greater use only

Pharmacy

The following forms only apply to plan participants enrolled in HealthLink OAP, Coventry Health Care OAP or the Quality Care Health Plan

• Medco Mail Order Form (submit for mail order if you have a prescription written)
• Express Scripts Mail Order Form (provide this form to physician to complete for mail order)
• Express Scripts Claim/Reimbursement Form

Vision Coverage

• EyeMed Claim Form (PDF 133 KB)