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

• 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

• Life Insurance Certificate
• Securian Financial(formerly Minnesota Life) Beneficiary Form
• Conversion Application (PDF)
• Election of Portability (PDF)
• Evidence of Insurability Application (PDF)
  

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 01/08/2019​​​