Consumer Coverage Disclosure Act Complaint Form

Illinois Department of Labor, Compliance Unit 

160 N. LaSalle - 13th Floor
Chicago, IL 60601
312-793-5257 (fax)
1. Check HERE if your employer did not provide you a list of written covered benefits included in the group health insurance.
a. If checked YES to the above statement, did your employer fail to provide you the list of written covered benefits uponCheck all that apply.
2. Please identify how your employer distributes health insurance informationCheck all that apply.
I confirm and certify the above information and statements made are true and correct to the best of my knowledge. Required