Forms

Address Change

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

Beneficiary Forms

• Group Life Insurance Program (PDF)
• 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)

Domestic Partner

• Termination of Group Insurance Coverage for Domestic Partner (PDF)

Enrollment/Change Forms

• Part-time Employee Election/Waiver of Group Insurance Participation (PDF) Part-time Employee working 50% or greater use only

Flexible Spending Accounts (FSA) Program

• DCAP Change in Status Form
• MCAP Change in Status Form
• MCAP COBRA Election Form
• MCAP Claim Form
• DCAP Claim Form

Health Coverage

• Aetna Cl​aim Form (PDF)

Leave of Absence

•  Leave of Absence Waiver (PDF)

Life Insurance

• Securian/Minnesota Life Beneficiary Form (PDF)
• Conversion Application (PDF)
• Election of Portability (PDF)
• Evidence of Insurability Application (PDF)

Opt Out & Waiver Forms

• Opt Out Election Certificate (PDF) - Full-time Employee, Annuitant and Survivor use only
• Opt Out Election with Financial Incentive Application (PDF) (SERS, SURS, TRS, JRS and GARS Non-Medicare Annuitants only)
• Part-time Employee Election/Waiver of Group Insurance Participation (PDF) - 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

• 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)

Updated 07/05/2018​​​