Group Benefits

Forms > BCBSIL

 

 
Enrollment Kit as One File
Tips for Submitting New Small Groups 2-150 Eligible Employees
BlueCross BlueShield of IL Full Enrollment Kit 2010
 
Enrollment Kit as Separate Forms
Producer/Employer New Business Checklist (20910 3/07)
Benefit Program Application (New Case Submissions 2-150)
Benefit Program Application Fillable Word Document
Benefit Plan Selection Form (7/10)
Employer Group Information Form (20561 8/05)
Medicare Secondary Payer Form (new business)
HIPPA Notice
Disclosure Form (EB4644 3/04)
Employee Application (20084.1008)
Additional Forms Not Included in the Enrollment Kit
Full-Time Status Certification for Owners, Partners or Proprietors NOT on Wage and Tax
Addendum to the Insured BPA Reguarding Affiliated Companies (MGA-10-1-ADD 2007 )
Spanish directions for the Small Group Employee Application (20535 07/04)
General Notice of Special Enrollment Rights & Preexisting Condition Exclusion (20742 07/05)
Affidavit of Domestic Partnership (20551 01/05)
 
Administrative Forms for "in force" Groups
Enrollment Change Request Form (EB4633 11/03)
Sample Broker of Record Letter (EB5063 5/01)
Cobra Notification Form
Cobra Election Form
BCBS Shortened BPA
Medical Claim Form
International Claim Form (N13-04-086)
Student Certification Form
Member PHI Release Form
Medicare Secondary Payer Form (in force)
BlueAccess For Employers Enrollment Form (Groups 2-50)
BlueAccess For Employees Enrollment Form (Groups 51+)
Benefit Plan Selection Form (1/10)
MSP Letter and Producer Notice IL
Statement of Termination of Domestic Partnership (20560 2/07)
Tax Information on Health Benefits for Domestic Partnership (20559 2/07)
State Continuation Instructions
Request for State Continuation Information
 
Prescription Drug Forms
Mail Service Prescription Drug Program Brochure (20158 2/06)
PrimeMail Non-HMO and HMO 90-Day Supply-Mail Service Order Form (20161 1/06)
PrimeMail Physician Fax Form (2560IL 2/05)
HMO 90-Day Supply Mail Service ONLY – Walgreens Mail Service Physician Fax Form (10/07)
Rx Drug Card and Fully Integrated BlueSCRIPT – Claim Form (20157 5/09)
BlueScript Electronic Claim Service – Claim Form (01103 12/06)
 
 
 
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