Address Change

• Address Change and Other Address/Addressee Information(PDF 26KB)

Beneficiary Forms

• Deferred Compensation (PDF 8 KB)
• Group Life Insurance Program (PDF 76 KB)
• Retirement System

Commuter Savings Program (CSP)

• CSP Claim Form [PDF 57, KB]

Dental Coverage

• CompBenefits Claim Form (PDF 80 KB)

Dependent Certification

• Dependent Certification Form (PDF 16 KB)

Domestic Partner

• Domestic Partnership Affidavit
• Domestic Partner Enrollment Form
• Domestic Partner Enrollment Packet (includes information and all forms)
• Termination of Group Insurance Coverage for Domestic Partner

Enrollment/Change Forms

• Part-time Employee Election/Waiver of Group Insurance Participation (PDF 116KB) Part-time Employee working 50% or greater use only
• Group Insurance Enrollment/Change Form (PDF, 64KB)– Employees use only (retirees and survivors must contact their retirement system)

Flexible Spending Accounts (FSA) Program

• DCAP Change in Status Form (PDF 19 KB)
• DCAP Enrollment Form (PDF 42 KB)
• FBMC Direct Deposit Form (PDF 83 KB)
• FSA Reimbursement Request Form (PDF 185 KB)
• MCAP Change in Status Form (PDF 20 KB)
• MCAP COBRA Election Form (CMS-334) [PDF, 115KB]
• MCAP Enrollment Form (PDF 44 KB)

Health Coverage

• CIGNA Claim Form for QCHP (PDF 24 KB)

Life Insurance

• Beneficiary Form (PDF 76 KB)
• Conversion Application (PDF 150 KB)
• Election of Portability (PDF 74 KB)
• Statement of Health Application (PDF 145 KB)

Opt Out & Waiver Forms

• Annuitant Waiver Form (PDF 9 KB) Annuitant use only
• Opt Out Election Certificate (PDF 27 KB) - Full-time Employee, Annuitant and Survivor use only
• Opt Out Election Certificate with Financial Incentive (PDF 20 KB) Non-Medicare SERS Annuitant use only
• Part-time Employee Election/Waiver of Group Insurance Participation (PDF 116KB) Part-time Employee working 50% or greater use only

Pharmacy

• Medco Claim Form (PDF 25 KB)
• Prescription Mail Order form – Health Alliance Illinois (PDF 59 KB)
• Prescription Mail Order form – HealthLink OAP (PDF 59 KB)
• Prescription Mail Order form – Humana Benefit Plan of Winnebago (PDF 59 KB)
• Prescription Mail Order form – Quality Care Health Plan (QCHP) (PDF 59 KB)

Vision Coverage

• EyeMed Claim Form (PDF 133 KB)