Forms

Address Change

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

Beneficiary Forms

• Group Life Insurance Program
• Retirem​ent System

Commuter Savings Program (CSP)

• CCD Parking Reimbursement Claim Form (PDF)
• Refund Claim Form (PDF)

Dental Coverage

• Delta Dental of Illinois Claim form (PDF)

Dependent Certification

• Eligibility Certification Statement (PDF)

Flexible Spending Accounts (FSA) Program

• MCAP Continuation Election Form
• MCAP Claim Form
• DCAP Claim Form

Health Coverage

• Aetna Cl​aim Form (PDF)
• HealthLink Claim Form (PDF)
  

Leave of Absence

•  Leave of Absence Waiver (PDF)

Life Insurance

• Life Insurance Certificate
• Securian Financial Beneficiary Form
• Conversion Application
• Election of Portability
• Evidence of Insurability Application
  

Pharmacy

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

• CVS Caremark® Mail Service Order Form (PDF)
• CVS Caremark® Mail Service Order Form - Spanish (PDF)
• CVS Caremark® Paper Claim Form (PDF)
• CVS Caremark® Paper Claim Form - Spanish (PDF)

Vision Coverage

• EyeMed Claim Form (PDF)

Last Updated 03/18/2020​​​