BCBSIL Group Forms

(847) 592-0941     Email Us     Contact Sheet

Plan Changes for In-Force Groups

Benefit Plan Selection Forms: Please contact the Group Service Team at 847.605.1200 to get details on when plan changes are allowed and paperwork is due.

Billing Method Form Only needed if your group is changing their billing method. Example: If they are currently Age Rated and are staying Age rated, there is no need to fill out this form.

Employee Application will be required for any employees changing plans or joining during open enrollment. If they are an existing member or not on an ACA Metallic plan the medical questions are not required.

Prescription Drug Forms

Rx Claim Form
Rx Info

Administrative Forms for In-Force Groups

Enrollment Change Request Form (EB4633 6/10)
Sample Broker of Record Letter
Medical Claim Form
Dental Claim Form
International Claim Form (N13-04-086)
Member PHI Release Form
Affidavit of Domestic Partnership
Statement of Termination of Domestic Partnership (20560 2/07)
Tax Information on Health Benefits for Domestic Partnership (20559 2/07)
Employee Application – All Size Groups
BCBSIL Ancillary Application
Medicare Secondary Payer Form (MSP)

Looking for earlier forms?

Contact Us

Resource Brokerage LLC
1501 East Woodfield Road, Ste 110e
Schaumburg, IL 60173
Toll Free: 1-800-605-7566
General Phone: (847) 605-1200


Phone: (847) 592-0941
Fax: (847) 605-1494


Phone: (847) 598-6006
Fax: (847) 605-1331

Life, Annuity, LTC, DI & CI

Phone: (847) 598-6005
Fax: (847) 619-9592


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About Us - Who We Are

Resource Brokerage is one of the Midwest’s leading FMOs, providing brokers a choice of Group Benefits, Major Medical, Life, Annuities, DI, LTC and Linked Benefits all in one place.

Brokers work with a team of dedicated professionals who specialize in the lines of business they support. These teams also constantly undergo training and education with a focus on credentials that mean the most to our industry. Our management team is led by seasoned industry professionals with true brokerage experience and the know-how to help get things done for our brokers.

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Please Note: The information on this website is for agent use only and is not intended for use by the general public.

While this website does not generate leads, leads are available to our brokers for purchase through our affiliation with Integrity through our proprietary software LeadCenter.